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ISLAMIC PERSPECTIVES ON THE
PRINCIPLES OF BIOMEDICAL ETHICS
29/6/16 8:23 AM
Intercultural Dialogue in Bioethics
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Series Editor: Alireza Bagheri
(Tehran University of Medical Sciences, Iran)
Published
Vol. 1
Islamic Perspectives on the Principles of Biomedical Ethics
edited by Mohammed Ghaly
Forthcoming
Islamic Bioethics: Current Issues and Challenges
by Alireza Bagheri and Khalid Abdulla Al-Ali
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Intercultural Dialogue in Bioethics — Vol. 1
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Series Editor: Alireza Bagheri
ISLAMIC PERSPECTIVES ON THE
PRINCIPLES OF BIOMEDICAL ETHICS
Muslim Religious Scholars and
Biomedical Scientists in Face-To-Face
Dialogue with Western Bioethicists
Editor
Mohammed Ghaly
Hamad Bin Khalifa University, Qatar
World Scientific
Q0014_9781786340474_tp.indd 2
Imperial College Press
29/6/16 8:23 AM
Published by
World Scientific Publishing (UK) Ltd.
57 Shelton Street, Covent Garden, London WC2H 9HE
Head office: 5 Toh Tuck Link, Singapore 596224
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USA office: 27 Warren Street, Suite 401-402, Hackensack, NJ 07601
Library of Congress Cataloging-in-Publication Data
Names: Ghaly, Mohammed, editor.
Title: Islamic perspectives on the principles of biomedical ethics / Mohammed Ghaly.
Description: New Jersey : World Scientific, [2016] | Series: Intercultural dialogue in bioethics ; v. 1 |
Includes bibliographical references and index.
Identifiers: LCCN 2016000558 | ISBN 9781786340474 (hc : alk. paper)
Subjects: LCSH: Medical ethics--Religious aspects--Islam--Congresses. |
Bioethics--Religious aspects--Islam--Congresses. | Islamic ethics--Congresses.
Classification: LCC R725.59 .I854 2016 | DDC 174.2--dc23
LC record available at http://lccn.loc.gov/2016000558
British Library Cataloguing-in-Publication Data
A catalogue record for this book is available from the British Library.
Copyright © 2016 by World Scientific Publishing (UK) Ltd.
All rights reserved. This book, or parts thereof, may not be reproduced in any form or by any means,
electronic or mechanical, including photocopying, recording or any information storage and retrieval
system now known or to be invented, without written permission from the publisher.
For photocopying of material in this volume, please pay a copying fee through the Copyright Clearance
Center, Inc., 222 Rosewood Drive, Danvers, MA 01923, USA. In this case permission to photocopy
is not required from the publisher.
In-house Editors: Chandrima/Mary Simpson
Typeset by Stallion Press
Email: enquires@stallionpress.com
Printed in Singapore
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Islamic Perspectives on the Principles of Biomedical Ethics
In memory of my father, Mustafa
His life full of meaningful experiences has played
a role in guiding me to the field of bioethics
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Islamic Perspectives on the Principles of Biomedical Ethics
Contents
About the Authors/Participants in the Seminar Deliberations
ix
Introduction
xv
Part I: Methodological Issues
1
Deliberations within the Islamic Tradition
on Principle-Based Bioethics: An Enduring Task
Mohammed Ghaly
3
The “Bio” in Biomedicine: Evolution, Assumptions,
and Ethical Implications
Muna Ali
41
A Maqāsid-Based Approach for New Independent Legal
Reasoning (Ijtihād)
Jasser Auda
69
Part II: Principles of Biomedical Ethics
89
The Principles of Biomedical Ethics as Universal Principles
Tom L. Beauchamp
91
Response by Ali Al-Qaradaghi to Tom Beauchamp’s Paper
Ali Al-Qaradaghi
121
vii
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viii Contents
The Principles of Biomedical Ethics Revisited
Annelien L. Bredenoord
133
Script of Oral Discussions (Day 1, Session 3)
153
Script of Oral Discussions (Day 2, Session 3)
177
Part III: Islamic Perspectives on the Principles
of Biomedical Ethics
209
Ethics in Medicine: A Principle-Based Approach in Light
of the Higher Objectives (Maqāsid) of Sharia
Ahmed Raissouni
211
Response by Hassan Chamsi-Pasha to Raissouni’s Paper
Hassan Chamsi-Pasha
233
Script of Oral Discussions (Day 1, Session 2)
241
Governing Principles of Islamic Ethics in Medicine
Abdul Sattar Abu Ghuddah
263
Response by Hassan Chamsi-Pasha to Abu Ghuddah’s Paper
Hassan Chamsi-Pasha
293
Script of Oral Discussions (Day 1, Session 1)
301
Formulating Ethical Principles in Light of the Higher Objectives
of Sharia and Their Criteria
Ali Al-Qaradaghi
317
Script of Oral Discussions (Day 3, Session 3)
341
Script of Concluding Discussions: Part One (Day 2: Session 1
and Session 2)
Script of Concluding Discussions: Part Two (Day 3: Session 1
and Session 2)
359
385
Conclusion: Critical Remarks
Tariq Ramadan
413
Glossary
419
Index
425
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About the Authors/Participants
in the Seminar Deliberations
Abdul Sattar Abu Ghuddah: Abdul Sattar Abu Ghuddah is a prominent
contemporary Muslim jurist and has written on Islamic medicine and
biomedical ethics. He obtained his B.A. in Islamic Law (1964) from
Damascus University and earned another B.A. in Law (1965) from the
same university. He continued his postgraduate studies in Egypt and
received his M.A. in Islamic Law (1966) and another M.A. in Hadith
sciences (1967). He earned a Ph.D. (1975) in Comparative Fiqh (Jurisprudence) from Al-Azhar University, Egypt. He is a member of the
International Islamic Fiqh Academy, Jeddah and also of the European
Council for Fatwa and Research. He is currently chairman and member of
the Sharia Supervisory Boards of several Islamic financial institutions. He
has authored books about the Islamic jurisprudence and rulings of contemporary issues and is a regular speaker at Islamic conferences and forums.
Mohammed Ali Al-Bar: Mohammed Al-Bar received from Cairo
University his MBBS degree with honors (1964) and his Diploma of
Internal Diseases (1969). He received membership in the Royal College of
Physicians (London, Edinburgh, and Glasgow) in February 1971 and
became a fellow of the Royal College of Physicians, London in 1994. After
his studies, he developed an interest in bioethics from an Islamic perspective and has since participated in meetings and discussions on Islamic
ix
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x
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About the Authors
jurisprudence and ethics, including those of International Islamic Fiqh
Academy, Jeddah; Islamic Fiqh Academy, Mecca; and the Islamic
Organization for Medical Sciences (IOMS), Kuwait. Dr. Al-Bar serves as
Director of the Medical Ethics Center, International Medical Center in
Jeddah and is an internal medical consultant and advisor of the Islamic
Medicine Department, King Fahd Center for Medical Research, King
Abdul-Aziz University, Jeddah. He has authored numerous publications on
bioethical questions, including organ transplantation, stem cell research,
sperm banks, AIDS, artificial insemination, abortion, contraception,
embryology, brain death, and Prophetic medicine. He has written numerous
books, one of which is the celebrated work known in English under the title
Human Development as Revealed in the Holy Qur’an and Hadith (2002).
Ali Al-Qaradaghi: Ali Al-Qaradaghi has founded numerous charitable
organizations and international Islamic jurisprudence bodies. He is
Secretary General of the International Union of Muslim Scholars. He also
serves as member of the Sharia Supervisory Boards of several banks in the
Muslim world. He headed the Department of Islamic Jurisprudence in the
College of Sharia and Islamic Studies at Qatar University. Al-Qaradaghi
has authored eight books, with several more in various stages of publication, on topics including Islamic jurisprudence and Islamic thought. He
completed his Ph.D. in Contracts and Financial Transactions from Al-Azhar
University in Cairo, Egypt, in 1985.
Jasser Auda: Jasser Auda is the Executive Director of the Maqasid Institute,
a global think tank based in London, and a Visiting Professor of Islamic Law
at Carleton University in Canada. He is a founding and board member of the
International Union of Muslim Scholars, Member of the European Council
for Fatwa and Research, Fellow of the Islamic Fiqh Academy of India, and
General Secretary of Yaqazat Feker, a popular youth organization in Egypt.
He has a Ph.D. in the philosophy of Islamic law from University of Wales
in the UK and a Ph.D. in systems analysis from University of Waterloo in
Canada. Early in his life, he memorized the Qur’an and studied Fiqh, Usul,
and Hadith in the halaqas of Al-Azhar Mosque in Cairo. He previously
worked as: Founding Director of the Maqasid Center in the Philosophy of
Islamic Law in London; Founding Deputy Director of the Center for Islamic
Legislation and Ethics (CILE) in Doha; Professor at the University of
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About the Authors xi
Waterloo in Canada, Alexandria University in Egypt, Islamic University of
Novi Pazar in Sanjaq, Qatar Faculty of Islamic Studies, and the American
University of Sharjah. He has lectured and trained on Islam, its law, spirituality, and ethics in dozens of other universities and organizations around the
world. He has written numerous books in Arabic and English, some of
which were translated to 20 languages.
Tom Beauchamp: Tom Beauchamp is a Professor of philosophy and is
Senior Research Scholar at Kennedy Institute of Ethics. He holds graduate
degrees from Yale University and Johns Hopkins University, where he
received his Ph.D. in 1970. In 1975, he joined the staff of the National
Commission for the Protection of Human Subjects of Biomedical and
Behavioral Research, where he wrote the bulk of the Belmont Report
(1978). Dr. Beauchamp’s research interests include the ethics of humansubjects research, the place of universal principles and rights in biomedical
ethics, and methods of bioethics. He has coauthored Principles of
Biomedical Ethics (6th edn., 2009), A History and Theory of Informed
Consent (Oxford, 1986), and The Human Use of Animals (Oxford, 2nd
edn., 2008, with four coauthors). Many of his articles on biomedical ethics
were collected and republished in 2010 by the Oxford University Press
under the title Standing on Principles: Collected Works.
Abdullah Bin Bayyah: Abdullah Bin Bayyah was born in 1935 in the East
of Mauritania. He studied in the Mauritanian centers of learning known as
Mahadhir. He was later sent to study law at the Faculty of Law in Tunisia
and was trained in the Tunisian courts in 1961. Sheikh Bin Bayyah is currently Professor of Islam at King Abdul-Aziz University in Jeddah and
Director of the Global Center for Renewal and Guidance, UK. He is former
Vice President of International Union of Muslim Scholars (IUMS). He
previously served as Minister of Education, Minister of Justice, and one of
the first Vice Presidents in Mauritania. He is a member of the International
Islamic Fiqh Academy affiliated with the Organization of Islamic
Cooperation, Jeddah. He has authored numerous publications and spoken
at length about the endurance of the Islamic legal tradition.
Annelien Bredenoord: Annelien Bredenoord is an Associate Professor of
Biomedical Ethics at UMC Utrecht, the Netherlands, where she teaches
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xii About the Authors
ethics at the Medical School. She received a VENI-grant to study the
ethics of pluripotent stem cell research. She is member of several committees, including the Young Health Council of the Netherlands, the Ethics
Committee of the Dutch Association for Clinical Genetics, UMC Utrecht’s
Research Ethics Committee (METC), and the International Stem Cell
Forum Ethics Working Party. Her interests include biomedical ethics with
an emphasis on ethical issues in regenerative medicine, stem cell research,
genetics/genomics, biobanking, and novel reproductive technology. She
studied theology and political science at Leiden University and obtained
her Ph.D. at Maastricht University.
Hassan Chamsi-Pasha: Hassan Chamsi-Pasha is Consultant
Cardiologist and Head of Non-Invasive Cardiology at King Fahd Armed
Forces Hospital in Jeddah, Saudi Arabia and a Fellow of the Royal
College of Physicians in Ireland, Glasgow, and London. He is the author
of 52 books on diverse health issues and 60 papers in peer-reviewed
medical journals. He was an advisory member to the Board of Directors
of the Saudi Heart Association and served as a member of the Board
of Directors of the Saudi Heart Association for 10 years. He serves as
Expert in the International Islamic Fiqh Academy, Jeddah. He is also a
member of the Editorial Board of Saudi Medical Journal and the
Editorial Board of the Journal of Heart Health.
Mohammed Ghaly: Mohammed Ghaly is currently Professor of Islam
and Biomedical Ethics at the research Center for Islamic Legislation &
Ethics (CILE), Qatar. In 1999, he did Islamic Studies in English at
Al-Azhar University in Cairo, Egypt and was awarded his Bachelor’s
degree with cum laude. In 2002, he completed his M.A. degree in Islamic
Studies also with cum laude from Leiden University, the Netherlands, and
in 2008 he received his Ph.D. from the same university. During the
period 2007–2013, Dr. Ghaly was a faculty member of Leiden University
and since 2011 he has been a faculty member of the Erasmus Mundus
Program; the European Master of Bioethics jointly organized by a number of European universities. In 2012, Dr. Ghaly was awarded the prestigious VENI grant (2012–2016) from the Netherlands Organization for
Scientific Research (NWO) for his research project “Islam and Biomedical
Ethics: The Interplay of Islam and the West.” In 2015, he received
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About the Authors xiii
another prestigious grant from the Qatar National Research Fund
(QNRF) for conducting the research project “Indigenizing Genomics in
the Gulf Region (IGGR): The Missing Islamic Bioethical Discourse.”
Besides his strong record of peer-reviewed publications on a wide range
of topics in the field of Islam and Biomedical Ethics, Dr. Ghaly serves on
the editorial board of a number of academic journals and is the research
consultant of a number of research projects as well. He has been invited
to lecture on Islamic bioethics at many universities worldwide including
Imperial College London, Oxford University, University of Oslo,
University of Chicago, and Georgetown University. During the academic
year 2014–2015, he was Visiting Researcher of the Kennedy Institute of
Ethics at Georgetown University, USA.
Ahmed Raissouni: Besides serving as Chairman of the League of Sunni
Scholars, Ahmed Raissouni is a member of the International Islamic Fiqh
Academy, Jeddah and is Vice President of the International Union of Muslim
Scholars. He is a Visiting Professor at Qatar Faculty of Islamic Studies and
was formerly a Professor of Fundamentals of Islamic Jurisprudence
(Usul Al-Fiqh) and Higher Objectives of Sharia (Maqasid Al-Sharia) at
Mohammed Al-Khamis University in Rabat, Morocco. His works include
those on the higher objectives of Sharia, Islamic political theories, and issues
of religious revival. He earned a degree in Sharia at the University of
Al-Qarawiyyin in Fes, Morocco and holds a doctorate in Islamic Studies
from Mohammed Al-Khamis University.
Tariq Ramadan: Tariq Ramadan is Professor of Contemporary Islamic
Studies at the University of Oxford (Oriental Institute, St Antony’s
College) and also teaches at the Oxford Faculty of Theology. He is Visiting
Professor at the Qatar Faculty of Islamic Studies; Senior research Fellow
at Doshisha University (Kyoto, Japan); and Director of the research
Center of Islamic Legislation and Ethics (CILE) (Doha, Qatar). He holds
an M.A. in Philosophy and French literature and Ph.D. in Arabic and
Islamic Studies from the University of Geneva. In Cairo, Egypt, he
received one-on-one intensive training in classic Islamic scholarship from
Al-Azhar University scholars (ijazat — authorization to teach — in seven
disciplines). Through his writings and lectures Tariq Ramadan has contributed to the debate on the issues of Muslims in the West and Islamic
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xiv About the Authors
revival in Muslim-majority countries. He is active at academic and
grassroots levels, lecturing extensively throughout the world on theology,
ethics, social justice, ecology, and interfaith as well intercultural dialogue. He is President of the European think tank European Muslim
Network (EMN) in Brussels. His books include The Arab Awakening:
Islam and the New Middle East (2012), The Quest for Meaning, Developing a Philosophy of Pluralism (2010), and Radical Reform, Islamic
Ethics and Liberation (2008).
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Islamic Perspectives on the Principles of Biomedical Ethics
Introduction
This volume originated from the proceedings of a three-day seminar
organized by the research Center for Islamic Legislation & Ethics (CILE)
in Doha, Qatar during the period 5–7 January 2013. Besides Tariq
Ramadan as CILE Executive Director, Jasser Auda as the then CILE
Deputy Director, and myself as the invited moderator from Leiden
University in the Netherlands to which I was affiliated at this time, the
seminar hosted eight participants from different backgrounds and specializations. The list of the participants included four Muslim religious
scholars, two Muslim physicians, and two bioethicists. The participating
Muslim religious scholars were Sheikh Ahmed Raissouni (Morocco),
Sheikh Abdul Sattar Abu Ghuddah (Syria) Sheikh Ali Al-Qaradaghi
(Qatar) and Sheikh Abdullah Bin Bayyah (Mauritania). The two Muslim
physicians were Hassan Chamsi-Pasha (Syria) and Mohammed Ali Al-Bar
(Saudi Arabia). The two bioethicists were Tom Beauchamp (USA) and
Annelien Bredenoord (the Netherlands). The participants’ contributions
varied between presenting a paper and/or responding to a paper written by
another participant. The only exception here was Sheikh Bin Bayyah, who
could write neither a paper nor a response, mainly because of his busy
schedule and poor health conditions at that time. In order to enhance the
xv
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xvi Introduction
interdisciplinary character of the seminar, we were keen that the author of
the paper and the respondent to the authored paper come from different
specializations.
In the light of a post-seminar critical evaluation of the proceedings
and the submitted papers, some new chapters were added in order to fill
in certain gaps. All the chapters included in Part I were written after the
seminar, and the same holds true for the chapter written by Annelien
Bredenoord included in Part II and the conclusion written by Tariq
Ramadan. One of the unique aspects introduced by this volume is incorporating the script of the oral discussions and deliberations that took place
among the participants during the seminar. I hereby want to thank the five
anonymous reviewers who were positive about the book in general and
specifically about this point. They shared with us the conviction that these
deliberations would be of added value and would provide a rich source of
information for a wide range of the expected readers of this work.
However, incorporating these deliberations was a considerably daunting
task especially because a substantial deal of the discussions was originally
in Arabic and had to be translated. This will lead me to the duty of showing my thankfulness for the great help provided by a great number of
people whose input was crucial for the successful completion of this project. To start with, the manuscript has benefitted from the professional
work done by many colleagues in the Imperial College Press and World
Scientific, and I am indebted to them all.
In the name of CILE, I have to acknowledge the generous financial
support given by Qatar Foundation throughout the lifetime of the project
starting from organizing the seminar up to this resulting publication.
I also feel deeply indebted to the two research assistants whose linguistic skills in both Arabic and English and their hard and dedicated work
were indispensable for bringing this publication to a satisfactory end.
Sarah el-Nashar exerted laudable efforts during the first phase of preparing this publication. Then Sarah handed her tasks over to Noor
Doukmak, who incessantly and meticulously worked on various manuscripts of this publication. She was patient enough to check and double
check the grammatical and stylistic correctness of the whole text besides
the exhausting work on the diacritics of the Arabic terms.
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Introduction xvii
Since I joined CILE in September 2013, I came to know colleagues
whose company did enrich my life experience not only as an academic
researcher but as a human being in the first instance. Whenever I needed
help during my work on this volume, I found them always helpful and
supportive. I am thankful to them all; Beula Haddad, Fatima Azzahrae
Chaabani, Mawahib Bakr, Mona Al Emadi, Badih Touiss, Chaoiki Lazhar,
Fethi Ahmed, Jasser Auda, Mohamed El-Moctar El-Shinqiti, Mokhtar
Lehmar, Muetaz Al Khatib, Ray Jureidini, and Tariq Ramadan.
I keep the final word here for my family, the light of my life, whose
dedicated support always helped me overcome serious obstacles and frustrating moments during my work on this project. I am wholeheartedly
thankful to my wife Karima, our twin daughters Khadija and Maryam, our
son Mustapha, our daughter Aisha, our new family member Hamza — the
lovely boy who saw life during this project — and last but not least my
mother Fawzia. I want to say to them, “My life is unimaginable without
you being the sweetest part of it. Thanks for everything and I hope I can
properly fulfill my duties towards you as husband, father, and son”.
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Mohammed Ghaly
Doha, Qatar
23 February 2016
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Part I
Methodological Issues
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Deliberations within the Islamic
Tradition on Principle-Based
Bioethics: An Enduring Task
Mohammed Ghaly
Abstract: This introductory chapter reviews the main attempts to formulate
principles of biomedical ethics that are either compatible with the Islamic
tradition or directly extracted from this tradition. To my knowledge, this
is the first review of available studies on this topic, which is why I tried to
make it as comprehensive as possible and to refer to each available study,
although some of them may include considerable overlap and sometimes
even repetition. The studies reviewed in this chapter were divided into
two main groups. The first group addressed a specific set of principles
introduced by Western bioethicists and tried to demonstrate its compatibility
with the Islamic tradition (Instrumentalist Approach). The other group tried
to develop a set of principles emanating from, and rooted in, the Islamic
tradition itself (Indigenous Approach).
The discipline of principle-based bioethics or principlism figured prominently in the West during the 1970s and early 1980s. Within this new
discipline, specific sets of principles were introduced as frameworks of
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4
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Islamic Perspectives on the Principles of Biomedical Ethics
evaluative assumptions hoping that these principles will give the then
embryonic field of bioethics some minimal coherence and uniformity. The
four-principle theory (autonomy, beneficence, nonmaleficence, and justice) introduced by the two American philosophers Tom Beauchamp and
James Childress in their work Principles of Biomedical Ethics remains
one of the most widely debated theories in the field of bioethics, with
arguments for and against it. One of the central propositions of Beauchamp
and Childress is that the four principles have a universal character and are
thus compatible with different cultures, traditions, and philosophies of
life. This point is already reflected in the title of Beauchamp’s contribution to this volume, namely, “The Principles of Biomedical Ethics as
Universal Principles.” The applicability of these four principles to different cultures, societies, and religious traditions has been examined and
debated by a great number of researchers, and the Islamic tradition is no
exception in this regard.
Despite the rich discussions within the Islamic tradition on a long
array of individual bioethical issues, the attention paid to the question of
its overall principles still remains immature. In a bid to fill in this gap and
to trigger more in-depth discussions on this topic, the research Center for
Islamic Legislation and Ethics (CILE) dedicated the first seminar in its
research field “Islam and Biomedical Ethics” to this issue. To put the
published proceedings of this seminar in their broader context, this introductory chapter will give an overview of the relevant discussions that
pre- or ante-dated the CILE seminar. To keep the systematic character of
this overview, the studies will be examined in two separate sections:
(i) Instrumentalist Approach and (ii) Indigenous Approach.
The first section will focus on the contributions whose authors tried
to show the compatibility of a certain set of principles, usually developed
by Western bioethicists, with the Islamic tradition. References in the
Qur’an and Sunna and, much less frequently, relevant discussions among
religious scholars or key (ethical) concepts in the Islamic tradition, are
quoted almost exclusively as an “instrument” in order to justify the compatibility of these principles with the Islamic tradition. Thus, the Islamic
tradition is not approached as a source of knowledge but as a possible
justifier for already existing assumptions embraced by principle-based
bioethics. The second section will examine the contributions whose
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Deliberations within the Islamic Tradition on Principle-Based Bioethics 5
writers tried to search for and develop a set of principles rooted in the
Islamic tradition. The starting point of the theorists of this approach is not
the principles developed outside the Islamic tradition; sometimes they are
even not aware of them. They try to formulate principles by fathoming out
the Islamic scriptures (Qur’an and Sunna) in addition to specific genres in
Islamic law (fiqh) and Islamic legal theory (usūl al-fiqh) such as the
Islamic legal maxims (qawāʿid fiqhīyah).
Before delving into the details of the different studies that fall within
either of these two sections, a brief note is due about two specific contributions with relevance to this topic. The term “principles” found its way into
contemporary Islamic bioethics already by the beginning of the 1980s
when this new field was roughly in its embryonic phase. To my knowledge, one of the earliest examples in this regard was the short paper written
by the Turkish Professor of Pediatrics, Yūnus Al-Muftu, entitled Mabādiʾ
al-akhlāq al-tibbīyah fī al-Islām (“Principles of Medical Ethics in Islam”).
This paper was presented during the First International Conference on
Islamic Medicine held in Kuwait during the period 12–16 January 1981.
Despite the interesting title Al-Muftu gave to the paper, he hardly said
anything about what these principles are or how to construe them. The
paper is considerably concise and gives a simple overview of scattered
issues relevant to the history of medical ethics in the Islamic tradition
espoused with references to towering figures in the field of medicine
throughout Islamic history like Ibn Sīnā (Avicenna).1 Also the criminologist Muhammad Al-Khani addressed the question of principles in his article “Al-Mabādiʾ al-akhlāqīyah allatī yajib an yatahallā bihā al-tabīb fī
mumārasatih li mihnatih al-tibbīyah” (“The Ethical Principles That a
Physician Should Follow in His Medical Profession”) published in 1988.
Al-Khani reviewed the international efforts to codify “principles of medical ethics” especially as far as combating torture is concerned. He referred
to the Declaration of Tokyo issued by the World Medical Association in
1975 and the code of “Principles of Medical Ethics” adopted by the UN
General Assembly in 1982. Despite scattered references to the standpoint
1
Yūnus al-Muftū (1981). Mabādiʾ al-akhlāq al-tibbīyah fī al-Islām, Al-Abhāth wa aʿmāl
al-muʾtamar al-ʿālamī al-awwal ʿan al-tibb al-Islāmī. Kuwait: Ministry of Public Health &
National Council for Culture, Arts and Letters: 550–552.
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of Muslim religious scholars to specific bioethical issues, Al-Khani was
basically interested in the influence of these principles on the codification
of law within or outside the Arab world rather than the possible (in)compatibility of these principles with the Islamic tradition.2
1. The Instrumentalist Approach
1.1. The Pioneering Contributions of G. Serour and K. Hasan
As far as the Instrumentalist Approach is concerned, there are two main
pioneers, namely the Egyptian Professor of Obstetrics and Gynecology
Gamal Serour (International Islamic Center for Population Studies and
Research, Al-Azhar University, Cairo, Egypt) and the Pakistani Professor
of Behavioral Sciences K. Zaki Hasan (Baqai Medical College, Karachi,
Pakistan). The two professors wrote two separate chapters, respectively
entitled “Islam and the Four Principles” and “Islam and the Four
Principles: A Pakistani View,” which both appeared in the first edition of
the edited volume Principles of Health Care Ethics, published in 1994.
Serour was quite aware of and was also an advocate of the four principles introduced by Beauchamp and Childress although their book does
not appear in Serour’s list of references. On the other hand, it seems that
Serour was not aware of the contribution of the Syrian religious scholar
Abu Ghuddah, which will be examined in the section “Indigenous
Approach.” The chapter starts with a couple of introductory remarks
about the four principles (to which Serour suggested adding a fifth one,
namely that the human person should not be subject to commercial
exploitation)3 and about the Islamic tradition, Sharia (defined by the
2
Muhammad al-Khānī (1988). Al-Mabādiʾ al-akhlāqīyah allatī yajib an yatahallā bihā al-tabīb fī
mumārasatih li mihnatih al-tibbīyah. Majallat al-Sharīʿah wa al-Qānūn 2: 129–197.
3
The standpoint of accepting the four principles, articulated by Beauchamp and Childress,
but also suggesting the addition of new principles, thought to be uniquely Islamic, was
adopted by other Muslim intellectuals. During a symposium held by Islamic Medical
Association of North America (IMANA) on end-of-life issues, the Muslim American physician Shahid Athar gave a presentation on “principles of biomedical ethics.” Athar started
by enlisting the four principles, and when he addressed the concept of “Islamic Medical
Ethics” in particular, he spoke about two principles, namely saving life and seeking a cure
(Athar 2011, 140). Strikingly enough, these exact two principles were also named by the
Code of Ethics of the Pakistan Medical and Dental Council issued in 2001 (article 7)
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Deliberations within the Islamic Tradition on Principle-Based Bioethics 7
author as the set of instructions which regulate everyday activity of life,
to be adhered to by good Muslims), and its primary and secondary
sources. After these introductory remarks, Serour laid out his bold thesis
by saying, “The primary sources of Sharia, namely Qur’an, Sunna and
sayings of the Muslim scholars, have stressed the four universally
accepted principles of ethics throughout Islamic history. The Islamic
Sharia has also given attention to the principle of protection of the human
subject against commercial exploitation.”4 The study is replete with
extensive quotations from the Qur’an and Sunna (Prophetic traditions)
that have been harnessed in order to support this thesis. Other authoritative texts, attributed to both pre-modern and contemporary religious
scholars, have also been used for the same purpose, however much less
frequently than the Qur’an and Sunna.
A uniform method was adopted throughout Serour’s study, namely
presenting a simple understanding of a certain principle (autonomy,
beneficence, nonmaleficence, or justice) followed by quotations from
authoritative texts in the Islamic traditions that, according to Serour, support the respective principle. Because of space limitations, we will only
examine here how Serour addressed the principle of autonomy, but it can
serve as an illustrative example of how he dealt with the other principles.
Autonomy was explained in one short sentence, “The principle of
autonomy implies respect for the person.”5 Directly thereafter follows a
long list of quotations from the Qur’an (12 Qur’anic verses) and Sunna
(five Prophetic traditions) to show how respect for persons has been
stressed in different ways. After this, Serour jumps to the bold conclusion,
“It is not therefore surprising that Islam, which ordered thinking, learning
among the elements that make Islamic bioethics different from Western bioethics. The
code is available online via http://www.pmdc.org.pk/Ethics/tabid/101/Default.aspx#7
(retrieved 17 August 2015). A more recent attempt to combine between condoning the four
principles (with some reservations on autonomy) and suggesting uniquely Islamic principles was done by the Muslim British physician Yassar Mustafa (Mustafa 2014, 479–483).
See Shahid Athar (2011). Principles of biomedical ethics. Journal of Islamic Medical
Association 43(3): 139–143; Yassar Mustafa (2014). Islam and the four principles of
medical ethics. Journal of Medical Ethics 40: 479–483.
4
G. Serour (1994). Islam and the four principles, in Raanan Gillon (ed.) Principles of
Health Care Ethics, 1st edn. London: John Wiley & Sons Ltd: 78–79.
5
Ibid., 79.
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and teaching would maintain autonomy and respect for the person in its
beliefs and religion.”6 What is striking here is that no attention is paid to
the sophisticated nature of a controversial concept like autonomy and its
different theories, as expansively discussed in mainstream Western bioethics. The same holds true for the extensive quotations from the Qur’an
and Sunna where no reference is made to the long-standing legacy of
Qur’an exegesis and commentaries on Prophetic traditions and how far
the interpretation proposed in Serour’s study would fit within or relate to
this legacy.
As for their relevance to contemporary medical practice, Serour also
argued that the four principles have been recently incorporated in the
medical oaths of several Islamic countries. He gave different examples of
these oaths, but the only one which, according to Serour, included autonomy in specific was the oath accepted by the aforementioned First
International Conference on Islamic Medicine held in Kuwait in 1981.
The following quotation from Serour’s study shows how specific texts are
“instrumentalized” to argue for the compatibility of the four principles
with the Islamic tradition7:
It [the medical oath] stated that the doctor will respect people’s dignity,
and their privacy, and will not disclose their secrets (autonomy). The
doctor will protect human life in all stages, in all circumstances and
conditions, and will do his utmost to rescue it from death, disease, pain,
and anxiety (beneficence). The doctor will strive in the pursuit of knowledge and harness it for the benefit of mankind and not for mankind’s
harm (nonmaleficence). He will extend his medical care to the near and
the far, to the virtuous and the sinner and to friend and enemy (justice).
It is to be noted that none of the four principles is mentioned in the
original text of the medical oath that Serour is referring to.8 He just
inserted each of the four principles, between brackets, after a certain
6
Ibid.
Ibid., 86.
8
ʿAbd al-Rahmān al-ʿAwadī (1981). Al-Abhāth wa aʿmāl al-muʾtamar al-ʿālamī al-awwal
ʿan al-tibb al-Islāmī, 2nd edn. Kuwait: Ministry of Public Health & National Council for
Culture, Arts and Letters: 700.
7
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Deliberations within the Islamic Tradition on Principle-Based Bioethics 9
sentence that, according to him, should be referring to this principle.
Although exploring a great number of the Islamic authoritative texts and
searching for their relevance to principlism is a credit for Serour’s pioneering study, an in-depth engagement with principle-based bioethics
remains missing. In a recent study of his published in 2015, Serour
touched again, but this time briefly, upon the four principles. He also
made reference to another set of principles, namely those included in the
2005 UNESCO Declaration. “These and almost all the ethical principles
in the UNESCO’s Declaration of Bioethics and Human Rights are supported in the primary sources of Sharia,” Serour reiterated.9,10
Like G. Serour, K. Hasan used the four principles developed by
Beauchamp and Childress as the starting point. Quotations from authoritative texts in the Islamic tradition or references to key ethical concepts
were employed mainly to show the compatibility of these principles with
the Islamic tradition. Most of the chapter is dedicated to examining the
“responses that Islam, as a metaphysical system based on faith, offers to
these four principles,”11 where each of the four principles was discussed
in a separate section. Adopting more or less the same line of thought and
reasoning used by Serour, Hasan unequivocally expressed his conviction
that these principles can be accommodated within the Islamic tradition,
e.g. “There is considerable room for personal autonomy in Islam,”
“Beneficence (birr) is one of the great pillars of the Message of Islam and
a clear way to social righteousness,” and, “These principles provide a
useful analytical framework for practitioners of medicine anywhere.”12
Only in a few places, Hasan referred to the differences between Western
societies and those of the Muslim world. For instance, he argued that
Western countries, especially those that did not have traditional societies
9
G. Serour (2015). What is it to practise good medical ethics? A Muslim’s perspective.
Journal of Medical Ethics 41: 122.
10
The same conclusion was reached by the Egyptian Professor of Philosophy, Bahaa
Darwish, when he addressed the principles included in the UNESCO Bioethics Declaration
from an Islamic perspective (Darwish 2014, 269–291). See Bahaa Darwish (2014). Arab
Perspectives, in Henk ten Have and Bert Gordijn (eds.) Handbook of Global Bioethics.
Dordrecht, the Netherlands: Springer: 269–291.
11
K. Zaki Hasan (1994). Islam and the four principles: A Pakistani view, in Raanan Gillon
(ed.) Principles of Health Care Ethics, 1st edn. London: John Wiley & Sons Ltd: 102.
12
Ibid., 96, 98, 102.
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like the United States and Scandinavian countries, managed to achieve a
high level of individual autonomy through a gradual process. However,
Hasan added, Islamic countries did not manage to achieve this because the
progress towards political autonomy has been extremely low. According
to him, such differences would explain the focus on family rather than the
individual in the Muslim world, where societies are essentially traditional,
and the subsequent different attitudes towards issues like informed consent or communicating bad news to the patients and their families. These
differences are not because of inherent variances between the concept of
autonomy and the Islamic tradition but because of the “cultural attitudes”
prevalent in Muslim countries like Pakistan.13
Unlike Serour, Hasan did not heavily depend on quotations from the
Qur’an and Sunna. Hasan’s references to the Qur’an are much less than
those of Serour; he includes only one direct quotation and the remaining
references allude to specific concepts in the Qur’an such as beneficence
and justice.14 In order to defend the compatibility of autonomy with Islam,
Hasan referred to the phenomenon of the quick spread of Islam throughout the world because it safeguarded individual liberty, which, he argued,
often went to great lengths. The Qur’anic concepts of divine lordship
(rubūbīyah) and human vice-regency (khilāfa) were also recalled by
Hasan to foster the “Islam-friendly” character of autonomy. “The Qur’an
says that the spirit of man is the divine spirit itself; if God is free, His
essential attribute of freedom is shared by man, being God’s vicegerent on
earth; hence he too possesses delegated freedom. Adam’s first exercise of
liberty was in disobedience,” Hasan argued. In the same vein, Hasan held
that the fact that divine revelation came to an end by the death of the
Prophet of Islam and that the development of the legal system is left to be
determined by the people in the light of their own reasoning demonstrates
that individual autonomy is not alien to the Islamic tradition.15
Another striking difference between the study of Serour and that of
Hasan is their approach to the role of Muslim religious scholars in the
contemporary debates on (bio)medical ethics. For Serour, the involvement
13
Ibid., 97, 98.
Ibid., 96, 98, 100.
15
Ibid., 96.
14
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Deliberations within the Islamic Tradition on Principle-Based Bioethics 11
of Muslim religious scholars in these debates was self-evident and positively viewed. He argued that in the absence of relevant references in the
Qur’an and Sunna, the opinion of religious scholars would be the reliable
reference. He also gave the example of the fruitful collaboration of
Muslim religious scholars with a great number of doctors, demographers,
lawyers, sociologists, ethicists, policy makers, and representatives of international organizations from all over the world (about 200 in total) during
the First International Conference on Bioethics in Human Reproduction
Research in the Muslim World, which was held during the period 10–13
December 1991. The deliberations during the conference resulted in a
proposed guideline on Bioethics in Human Reproduction Research in the
Muslim World.16 However, Hasan commenced his study by speaking
about the problem of “the wide gulf that exists in most Islamic — indeed
all Third World — countries between the clerical and the professional
groups.”17 According to him, this gulf happened because of significant
socio-political and cultural changes in society. In the pre-colonial era,
Hasan explained, the prevailing traditional medical system in the Indian
subcontinent, called Unani (lit. Greek), was an eclectic synthesis of more
ancient systems, mainly Greek and in a lesser degree Indian and old
Persian in addition to a mixture of other exotic and hardly identifiable
systems. The practitioners of that system came from the same stratum of
society to which religious scholars also belonged. Thus, the teacher,
cleric, and healer shared a common role in society and also a common
culture. During the colonial era, this traditional system was replaced by
the modern Western system, which was adopted by the emerging Westoriented group who became more and more westernized. By time, the
practitioners of traditional systems of medicine continued to have more in
common with religious scholars, essentially because of a common spiritual content, but got more and more isolated from the professionals who
practice modern systems of medicine. Hasan also added an epistemological reason for the supposed gulf between medical professionals and religious scholars. Unlike the Christian clergy, he argued, Muslim clerics did
not have state’s direct or indirect authority and society changed into groups
16
17
Serour (1994), op. cit., 73, 87.
Hasan (1994), op. cit., 93.
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of hierarchical families rather than guilds or fraternities with their own
codes of honor. This new situation left little room for intellectual dialogue
not only between religious scholars and physicians but also between
clerics and the various scientific professions.18
Hasan’s note about the supposed gulf, and absence of dialogue,
between religious scholars and physicians triggers critical remarks. First
of all, arguing that this gulf does exist not only in the Indian subcontinent,
but is also prevalent throughout the Muslim world and even the whole
Third World cannot be taken without reservations. In addition to Serour’s
abovementioned remarks, which counter-argue the veracity of Hasan’s
claim as far as Egypt is concerned, one can also refer to the series of five
International Conferences on Islamic Medicine held during the period
1981–1988 that witnessed a close collaboration between religious scholars and medical professionals. It is to be noted that the fourth conference
in this series took place in Karachi, Pakistan during the period 9–13
November 1986 and the then Pakistani Prime Minister, Muhammad Khan
Junejo, delivered the inaugural speech. The conference was attended by
more than 100 participants including, among others, religious scholars
and physicians.19
1.2. The Contributions of the Turkish Researchers
S. Aksoy, A. Elmali, and A. Tenik
The two Turkish researchers at Harran University, Sahin Aksoy (Faculty
of Medicine) and Abdurrahman Elmali (Faculty of Theology) presented
their study “The Core Concepts of the ‘Four Principles’ of Bioethics as
Found in Islamic Tradition” during the international conference “Medical
Law and Ethics in Islam,” held in March 2001 at the University of Haifa.
The study of Aksoy and Elmali was published in 2002, together with the
proceedings of the conference as a thematic issue in the Journal of
18
Ibid., 93, 94.
Sayf al-ʿAlī, Ahmad al-Jundī and ʿAbd al-Sattār Abū Ghuddah (eds.) (1986). Al-Abhāth
wa aʿmāl al-muʾtamar al-ʿālamī al-awwal ʿan al-tibb al-Islāmī 1. Kuwait: Islamic
Organization for Medical Sciences & Kuwait Institution for the Advancement of Science.
19
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Deliberations within the Islamic Tradition on Principle-Based Bioethics 13
Medicine and Law.20 Although the authors were well acquainted with the
works of the British bioethicist, Raanan Gillon, and had already quoted
two of his works in their study, they did not make any reference to the two
aforementioned studies written by Serour and Hasan in Principles of
Health Care Ethics that Gillon edited. Like the other studies in the
Instrumentalist Approach, the starting point of Aksoy and Elmali’s study
is that the four principles articulated by Beauchamp and Childress are
compatible with Islam and a relatively big number of quotations from the
Qur’an and Sunna (at least six times each) were employed to support this
thesis with an average of one Qur’anic verse or Prophetic tradition on
every page.21
One of the credits of this study is the much more in-depth presentation
of the theoretical underpinnings of the four principles. It is worth noting
that these two authors are the first to directly quote from the work of
Beauchamp and Childress by consulting its fourth edition published in
1994. This helped them give more accurate and nuanced information
about the principle-based bioethics. It seems that the educational background of Sahin Aksoy was a key element in this regard. He did his Ph.D.
in bioethics at Manchester University, where he studied with the prominent bioethicist, John Harris, for 5 years.22 Unlike Serour and Hasan who
usually inclined to give only a very brief, sometimes insufficient, overview of each of the four principles, Aksoy and Elmali dedicated a substantial deal of their study to the position of the principle-based theory in
Western bioethics and to a number of relevant concepts like common
morality, coherence theory of justification, reflective equilibrium, and the
processes of specification and balancing. The two authors were also keen
to stress and explain certain nuances when they presented information
about specific principles. For the principle of respect for autonomy, they
referred to the distinction made between one’s capacity for self-rule and
another’s reaction to that capacity and between the autonomy of the
patient and that of the physician. Also for the principle of justice, they
20
Sahin Aksoy and Abdurrahman Elmali (2002). The core concepts of the ‘four principles’
of bioethics as found in islamic tradition. Journal of Medicine and Law 21: 211–224.
21
Ibid., 216–218, 220–223.
22
Sahin Aksoy (2010). Some principles of Islamic ethics as found in Harrisian philosophy.
Journal of Medical Ethics 36: 226.
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paid attention to the distinctions to be made between its different categories like distributive justice, rights-based justice, and legal justice and
between the different perspectives towards justice that were developed by
utilitarian, libertarian, and communitarian theories.23 Unfortunately, these
nuances are missing in the authors’ presentation of the Islamic perspective
on these principles, which usually took the form of generalizing, sometimes even simplistic statements. For instance, they used one of the
Prophetic traditions proscribing force-feeding for patients as evidence that
Islam supports the principle of autonomy and that food in the tradition can
be read as medication or treatment.24
Another significant feature of Aksoy and Elmali’s study is their outspoken interest to “make a contribution to the mutual dialogue and understanding between two radically different traditions namely Islamic and
Western ones.”25 The claim that we here speak about “two radically different traditions” is hardly proven in their study, which has been trying
constantly to show the compatibility of the four principles, presented as a
product of the Western tradition, with the Islamic tradition. However, the
authors did make a number of references to some (significant) differences
between the two traditions concerning ethics in general and bioethics in
particular. According to the authors, the four-principle theory belongs to
the category of philosophical ethics whose premise is the psychological
constitution of man’s nature and the obligation laid on him as a social
being. On the other hand, the premise of Islamic or theistic ethics in general is God as the Ultimate Unity and the sole Creator of the whole universe and thus it stresses the religious basis of morality. The basic
assumption of Islamic ethics, the authors added, starts with faith in God,
and morality is the attempt of each individual as well as society to
approach Him and be obedient to His ordinances. As for the principle of
autonomy in specific, the two authors clarified that Islam sometimes puts
limits to one’s individual autonomy because acting with knowledge (‘ilm)
has a higher priority than acting according to one’s own wishes. Thus, it
will be ethically justified from an Islamic perspective, the authors argued,
23
Aksoy and Elmali (2002), op. cit., 215, 216, 220.
Ibid., 216, 217.
25
Ibid., 224.
24
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Deliberations within the Islamic Tradition on Principle-Based Bioethics 15
to oblige the patient or authorize the physician to protect the former’s
health and life once there is a prevailing opinion or a fairly certain presumption based on “knowledge.” They gave the example of the religious
obligation to eat a necessary amount of food in case of extreme hunger,
even if the only available type of food at the time is in normal circumstances religiously forbidden, in order to stay alive. They justified this
obligation that may conflict with the principle of respect for autonomy by
saying, “Since eating is a treatment itself in those cases, the autonomous
decision of the individual is irrelevant as there is a ‘prevailing opinion’
that failing to act accordingly will harm health and life.”26
In 2002, Sahin Aksoy collaborated with another Turkish Muslim
theologian, Ali Tenik, and published together an article entitled “The
‘Four Principles of Bioethics’ as Found in 13th century Muslim Scholar
Mawlana’s Teachings.” The motive behind this study aligns with that of
the previous study conducted by Aksoy and Elmali. As clearly explained
by Aksoy and Tenik, this study is also meant to “make a positive contribution to the mutual dialogue and understanding between two different traditions with common origins (both being ‘Abrahamic’), namely Islamic and
Western ones.”27 The author made reference to the study of Serour and the
study coauthored by Aksoy and Elmali but did not engage in dialogue
with these two studies. The authors of this study focused on the works of
the Persian mystic and poet Jalāl al-Dīn Rumi (1207–1273).28 It seems
that selecting Rumi in particular was meant to save the main objective of
the study, namely nurturing the East–West dialogue. They argued that
Rumi has not only influenced the East but also the West, as demonstrated
by the writings of the French De Wallenbourg (d. 1806), the Austrian Von
26
Ibid., 214–216, 218, 219.
Sahin Aksoy and Ali Tenik (2002). The ‘four principles of bioethics’ as found in 13th
century Muslim Scholar Mawlana’s Teachings. BMC Medical Ethics 3(4): 6.
28
A similar attempt was also made by two other Turkish researchers, namely H. Ozden and
O. Elcioglu. They argued that the four principles articulated by Beauchamp and Childress
have already existed in the work of the 11th century Turkish poet Yusuf Khass Hajib,
Kutadgu Bilig (Wisdom That Brings Good Fortune). See H. Ozden and O. Elcioglu (2008).
Sample from 11th century: Kutadgu Bilig and the four principles of bioethics. Iranian
Journal of Public Health 37(2): 112–119.
27
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Hammer-Purgtall and the German Friedrich Ruckert, Helmut Ritter, Hans
Meinke, and Goethe.29
As far as the four principles are concerned, the article did not add
anything new to what was mentioned in the previous study conducted by
Aksoy and Elmali to the extent that some sentences were even literally
repeated. As typical for the Instrumentalist Approach, the works of Rumi
were not approached as a sovereign source of information and possible
locus for a set of principles relevant to the field of medical ethics. They
were rather “instrumentalized” in the sense that they were consulted just
to check the compatibility of the four principles introduced by Beauchamp
and Childress with Rumi’s moral thoughts.
For the principle of respect for autonomy, the two authors elaborated
a bit more on the idea raised in Aksoy and Elmali’s previous study about
the significance of acting on the basis of knowledge (‘ilm) rather than
one’s own wishes. According to Rumi, Aksoy and Tenik argued, man is a
supreme creature granted with ‘ilm and, therefore, has an inherent right to
choose and that man’s decision shall be respected once it is taken autonomously with ‘ilm. The authors highlighted another important element for
understanding autonomy in Rumi’s moral thought, namely the interaction
and balance between God’s intervention and man’s will power in every
action. Thus, man wants and God creates, and man’s freedom of choice is
itself created with God’s will, as stated by Rumi. Aksoy and Tenik were
aware that this perspective can be interpreted to mean something different
than the principle of autonomy as understood in Western bioethical literature. In order to repel this claim, they concluded their discussion for this
principle by saying that autonomy in the Rumi’s teachings is in fact “a
first order autonomy with the ‘share’ of God in it, and shall be respected,
provided that it is done with ‘ilm.”30
A great deal of the article was dedicated to the two principles of
beneficence and nonmaleficence whose discussion was merged in one
rubric. After a short explanation of what these two principles mean in
Western bioethical discourse, the authors picked a number of Rumi’s
thoughts that they saw relevant and supportive for the purport of these two
29
30
Aksoy and Tenik (2002), op. cit., 6.
Aksoy and Tenik (2002), op. cit., 3.
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principles. For instance, they referred to Rumi’s Mathnawi, in which he
held that being helpful to someone who is ill or has some problems is a
form of a charity. Also, in Rumi’s eyes, the ideal man is the one who overcomes his egoism and commits himself to be beneficial not only to fellow
humans but to all creatures of God. Again like the principle of autonomy,
the authors had to defend the compatibility of the principle of autonomy
with Rumi’s teachings and with Islam in general, despite what seems to
be contradiction. On one hand, beneficence is usually defined as acting in
the interest of others whereas in Islam God promises a generous reward in
return for being beneficent. This might imply, the authors explained, that
self-interest or egoism is the most important facilitator or motivation of
man’s altruistic behavior, which is contrary to the abovementioned definition of beneficence. However, the authors argued that while self-interest
can be one of the motivations, it is not the major one especially in the
mindset of a mature Sufi. Here one easily notices how apologetic the contributions within the Instrumentalist Approach can be in their bid to
legitimize the embracement of the four principles, sometimes at the cost
of serious engagement with the Islamic tradition. The claim that motivations related to the Hereafter, in this case receiving God’s reward for
benefiting others, do not play a major role in the Islamic tradition cannot
be simply thrown around without in-depth analysis and rigorous argumentation. The general impression here is that specific components of the
Islamic tradition are twisted in order to make them fit within the fourprinciple theory.
In 2010, Sahin Aksoy published his paper “Some Principles of Islamic
Ethics as Found in Harrisian Philosophy,” whose very title already betrays
some of the aforementioned features of the Instrumentalist Approach.
Unlike the previous studies that Aksoy coauthored with Elmali and Tenik
whose focus was the four-principle theory articulated by Beauchamp and
Childress, the main focus of this new study was the positions developed
by the British bioethicist John Harrison on a number of key bioethical
issues. Speaking about “principles of Islamic ethics” in the title is somehow misleading because it is not the author’s intention to construct or to
introduce specific “principles” in the technical sense. Rather, the study is
meant to highlight the similarities (seen to be greater than the differences)
between the Harrisian philosophy and the Islamic ethical tradition.
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The paper is divided into six main sections, each of which addressed a
specific issue/principle: responsibility; side-effects and double-effects;
equality; vicious choice, guilt, and innocence; organ transplantation and
property rights; and advance directives. Following more or less the previous studies’ line of argumentation, each section starts with the ideas and
positions adopted by John Harris on the respective issue then goes on to
the justification for why these ideas/positions are compatible with Islam.31
One of the main differences between this study and the two previous
ones is that the conclusions of this new study about the supposed compatibility between Western bioethics (represented here by John Harris) and
the Islamic tradition are much bolder, more controversial, and less
grounded. One example should suffice in this respect. In the section on
organ transplantation and property rights, Aksoy referred to, according to
him, Harris’s widely criticized view that the deceased’s prior consent for
organ removal, although ideal, is not necessary. According to Harris,
deceased people cannot be wronged or harmed by the transplant of their
organs “against their will” simply because they have no will. Immediately
thereafter, Aksoy jumps to the bold conclusion that Harris’s controversial
suggestion of making cadaver organs available for public benefit is parallel to the opinion of the Muslim religious scholar Ibn Qudama expressed
six centuries ago when he permitted the reuse of organs of the deceased!
Strikingly enough, Aksoy did not consult the works of Ibn Qudama but
based his claim on a secondary source that attributed this opinion to Ibn
Qudama. That Ibn Qudama spoke about organ transplantation or organ
donation is itself an extremely controversial issue that I have addressed
elsewhere.32 What is far-fetched here is claiming that Ibn Qudama, six
centuries ago, adopted the same position as that of John Harris whereas
contemporary Muslim religious scholars still strongly debate on the
(im)permissibility of organ donation in principle! Also unlike the previous
study which touched, albeit briefly, upon the potential bioethical
differences between the Western and Islamic traditions, this new study did
not elaborate on any possible difference. However, Aksoy noted that once
31
Aksoy (2010), op. cit., 226–229.
Mohammed Ghaly (2010). Islam and Disability: Perspectives in Theology and
Jurisprudence. London: Routledge, 127.
32
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Deliberations within the Islamic Tradition on Principle-Based Bioethics 19
we move from the issues of bioethics (should read here principles or
theoretical issues) to practical applications, e.g. abortion and euthanasia,
one could come across significant and fundamental differences between
Harrisian philosophy and Islamic ethical principles. According to Aksoy,
this is not surprising because it has here to do with religion-based ethics
on one hand and “a materialist, rationalist, utilitarian (may be atheist)
20th century philosopher,” on the other hand.33
1.3. The Contributions of the Saudi-based Physicians,
M. Al-Bar, H. Chamis-Pasha, and A. Al-Bar
The two Saudi-based physicians Muhammad Ali Al-Bar (International
Medical Center) and Hassan Chamis-Pasha (King Fahd Armed Forces
Hospital) have made three important contributions. In 2012, they published Mawsū‘at akhlāqīyāt mihnat al-tibb (Encyclopedia of the Ethics of
the Medical Profession), which they coauthored with a third physician,
‘Adnān Al-Bar. The authors dedicated the first chapter of this voluminous
work to the main ethical theories, particularly utilitarianism and deontology, and their relevance to the field of (bio)medical ethics. Tom
Beauchamp and James Childress were presented as two prominent bioethicists of the modern time, and their work Principles of Biomedical Ethics
was introduced as an essential textbook for researchers in this field. The
authors consulted the fifth edition of the book, which was published in
2001. What is unique about the Encyclopedia is that the authors, unlike
their predecessors, were not primarily concerned about the possible
(in)compatibility of the four principles with the Islamic tradition. Rather,
they provided a detailed review of the critical remarks raised by Beauchamp
and Childress about the two ethical theories of utilitarianism and deontology. By doing this, they managed to highlight the philosophical background of the principle-based bioethics, which is usually missing in the
other writings. However, the authors did not develop an overall Islamic
perspective on these two theories nor on the remarks raised by Beauchamp
and Childress. They rather gave sporadic comments on specific and
concrete issues that they came across while presenting the views of these
33
Aksoy (2010), op. cit., 229.
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two American bioethicists such as honesty towards the patient, confidentiality, and euthanasia.34
The authors directed a few critical remarks to Beauchamp and Childress,
and we pay attention here to one of them because it was a point of discussion, especially between Beauchamp and Mohammed Al-Bar, during the
symposium held by CILE in 2013. The authors spoke about the example of
poor African-Americans who suffer from hypertension but cannot be properly treated because they have no health insurance. Guided by the utilitarian
approach, some researchers argued that it is not efficient to spend money on
examining this group of patients because they have no regular access to
medical care anyhow. The authors of the Encyclopedia expressed their
strong dissatisfaction with this conclusion and lamented these researchers
for condoning and even defending the injustice of this deplorable and despicable system instead of criticizing it. Beauchamp and Childress were also
criticized for quoting the studies conducted by these researchers without
expressing their objection to their conclusions, which would implicitly indicate their agreement with these researchers.35 During the CILE symposium,
this issue was a subject of intensive discussions, and Tom Beauchamp was
keen to explain his standpoint and that neither he nor his colleague, James
Childress, ever embraced these conclusions. Readers of this volume can
follow the detailed discussions about this point especially in the chapter
written by Beauchamp and the subsequent deliberations.
The possible compatibility of the four principles with the Islamic tradition was the focus of two other studies conducted by Mohammed Al-Bar
and Hassan Chamsi-Pasha, which were published respectively in 2013
and 2015.36 Al-Bar and Chamsi-Pasha were aware of the previous studies
conducted by Serour and those coauthored by Aksoy, Elmali, and Tenik.
The study of Aksoy and Elmali was particularly central for Al-Bar’s and
34
Muhammad ʿAlī al-Bār, ʿAdnān al-Bār and Hassān Shamsī Bāshā (2012). Mawsūʿat
akhlāqīyāt mihnat al-tibb. Jeddah, Saudi Arabia: Sheikh Mohammed Hussien Al-Amoudi
Chair of Biomedical Practice Ethics.
35
Ibid., 63, 64.
36
Hassan Chamsi-Pasha and Mohammed Albar (2013). Western and Islamic bioethics:
How close is the gap? Avicenna Journal of Medicine 3(1): 8–14; Mohammed Ali al-Bar
and Hassan Chamsi-Pasha (2015). Contemporary Bioethics: Islamic Perspective.
Dordrecht, the Netherlands: Springer: 106–152.
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Chamsi-Pasha’s 2013 study, which inspired them with different ideas, e.g.
the difference between secular and religious ethics. It seems that Al-Bar
and Chamsi-Pasha were inspired by the very motive behind addressing
this issue to the extent that they even used identical phrases to the ones
used by Aksoy and Elmali: “It is hoped that this paper will make a contribution to the mutual dialogue and understanding between two radically
different traditions namely Islamic and Western ones.”37
Both studies of Al-Bar and Chamsi-Pasha reflect many of the typical
characteristics of the Instrumentalist Approach such as the extensive quotations from the Qur’an and Sunna to reach direct conclusions without
serious engagement with the long-standing tradition of related disciplines
in the Islamic tradition, including the Qur’an exegesis. The short study
published in 2013 included about 18 references to the Qur’an and 20 references to the sayings of Prophet Muhammad, and the long study published in 2015 included more references.38 These references are usually
amassed to strengthen the authors’ main argument that the four principles
are culturally sensitive, can be easily found in these two scriptural sources
and in the teachings of Muslim scholars, and thus are generally compatible with Islam. For instance, the two authors explained the position of
William Frankena on the principle of beneficence and its possible division
into four general obligations.39 Thereafter, a Prophetic tradition is quoted,
or actually instrumentalized, to show its compatibility with Frankena’s
ideas. The authors found it amazing that the Prophet of Islam did enjoin
Muslims to follow the obligations mentioned by Frankena. In the study
published in 2013, they could justify only three of the four obligations
mentioned in Frankena’s list, but in their study published in 2015 the
fourth obligation was also couched in Islamic garb.40
It is to be noted, however, that the two authors also stressed the differences between the Islamic tradition and the principle-based bioethics,
perhaps more forcefully than any of the previous studies. They differentiated between medicine as a medical profession and medical ethics.
37
Chamsi-Pasha and Al-Bar (2013), op. cit., 13.
Ibid., 9–12; Al-Bar and Chamsi-Pasha (2015), op. cit., 106–152.
39
(1) One ought not to inflict evil or harm; (2) One ought to prevent evil or harm; (3) One
ought to remove evil or harm; and (4) One ought to do or promote good.
40
Chamsi-Pasha and Al-Bar (2013), op. cit., 11; Al-Bar and Chamsi-Pasha (2015), op. cit., 121, 122.
38
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Although the practice of medicine now almost everywhere — including
in the Muslim world — follows the Western pattern, medical ethics which
judges this practice may be different. “This means that the use or non-use
of a renowned medical treatment by Muslim doctors will sometimes be
guided more by ethics derived from Islamic law than by purely medical
considerations,” the two authors argued.41 The stress on the differences
was particularly visible when the authors discussed the principle of autonomy. They differentiated between what they called “Western type of
autonomy” and “Islamic autonomy.” The Western type of autonomy was
characterized by a Western attitude of individualism according to which
the patient usually decides in disregard of external interventions, including those of one’s own family or wider society, and the health provider
plays the role of a bystander who just provides data. As far as Islamic
autonomy is concerned, the authors explained, the Western attitude of
individualism is not accepted. First of all, the patient is not allowed to act
as he/she wishes because of the binding rules mentioned in the Qur’an and
Sunna that Muslims have to follow. Also familial and social considerations play a role in various decisions to be made by or for the patient.
Additionally, Islamic autonomy does not mean that the health provider
should have a passive role but on the contrary should play an active role
in encouraging the patient to avoid health-related risky behavior and a
harmful lifestyle. Within this framework, a patient’s autonomy will never
entitle the physician to terminate any human life under his/her care.42
1.4. Collective Contributions
All the abovementioned studies were produced by individual researchers.
With the exception of the two Turkish theologians who coauthored the
two studies conducted by Sahin Aksoy, all the involved researchers were
trained in the field of medicine rather than Islamic studies. Although none
of the Islamic institutions dedicated a specific seminar or conference to
addressing the issue of principle-based bioethics from an Islamic perspective, they did touch upon this issue within the context of ethical guidelines
41
42
Chamsi-Pasha and Al-Bar (2013), op. cit., 8.
Ibid., 10, 11; Al-Bar and Chamsi-Pasha (2015), op. cit., 109, 110.
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Deliberations within the Islamic Tradition on Principle-Based Bioethics 23
for conducting research on human subjects. The Islamic Organization for
Medical Sciences (IOMS) is known for addressing bioethical questions
through a collective approach combining between physicians and religious scholars. During the period 11–14 December 2004, the IOMS held
an international symposium whose proceedings were published as
Al-Mīthāq al-Islāmī al-‘ālamī li al-akhlāqīyāt al-tibīyah wa al-sihhī yah
(The International Islamic Code for Medical and Health Ethics), which
was released concurrently in both Arabic and English.43 The second part
of the code, which was dedicated to the ethical guidelines for biomedical
research involving human subjects, touched upon the question of principles. In its 17th session held during the period 24–26 June 2006 in Jordan,
the International Islamic Fiqh Academy (IIFA) endorsed the IOMS ethical
guidelines and specifically the principles included therein (http://www.
iifa-aifi.org/2223.html).
The whole set of these ethical guidelines, including the principles,
were not developed by the participants in the IOMS symposium but were
rather imported from the “International Ethical Guidelines For Biomedical
Research Involving Human Subjects,” a document produced by the
Council for International Organizations of Medical Sciences (CIOMS).
As far as the principles are concerned, the document did not use the
famous set of four principles articulated by Beauchamp and Childress.
The CIOMS document adopted the three principles outlined in the wellknown Belmont Report that was written by the US National Commission
for the Protection of Human Services of Biomedical and Behavioral
Research, released in April 1979.44 The three principles are respect for
persons, beneficence, and justice. Within this set of principles, autonomy
is included as part of the principle of respect for persons, and beneficence
is introduced as a broad principle that conveys the two concepts of beneficence and nonmaleficence that count as two distinct principles in the
43
ʿAbd al-Rahmān al-ʿAwadī and Ahmad al-Jundī (2005). Al-Mīthāq al-Islāmī
al-ʿālamī li al-akhlāqīyāt al-tibīyah wa al-sihhīyah. Kuwait: Islamic Organization for
Medical Sciences; Abdul Rahman al-Awadi and Ahmad Rajai El-Gendy (2005). The
International Islamic Code for Medical and Health Ethics. Kuwait: Islamic Organization
for Medical Sciences.
44
Jennifer Sims (2010). A brief review of the Belmont Report. Dimensions of Critical Care
Nursing 29(4): 173–174.
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approach of Beauchamp and Childress and their like-minded bioethicists.45 Tom Beauchamp was member of the US Commission, and he
participated in writing the Belmont Report while he was concurrently
busy with finalizing the manuscript of the first edition of Principles of
Biomedical Ethics that was published in 1979 as well. Thus, the two sets
of principles are somehow interrelated, although certainly not identical.
The CIOMS document was translated into Arabic and then reviewed
by a committee composed of both Muslim religious scholars and biomedical scientists including J. Bryant, who was the CIOMS ex-President
and one of the developers of the CIOMS document. The committee was
entrusted with the task of providing an Islamic religioethical framework
for the document. Thus, the Islamic tradition is not approached as a possible source for certain principles but as a justifying instrument so that it
can be eventually argued that these principles are compatible with Islam.
It seems that this method goes in line with the aim of the IOMS to produce
a code of ethics that has both an international character and also an
Islamic tincture, as it appears in the very title of the code. The CIOMS
document already had the international character, and the selected committee was asked to add the missing element, namely the Islamic tint.
Otherwise, the members of the committee could have worked in a different way and thus would have produced something different. For instance,
they could have started from the pioneering study made by the Syrian
religious scholar Abdul Sattar Abu Ghudda that set the ground for the
Indigenous Approach. Strikingly enough, as we shall see below, Abu
Ghudda’s study was first introduced in the Second International Conference
on Islamic Medicine held in Kuwait in 1982 that was convened by the two
key figures who led the IOMS later, namely Abd Al-Rahman Al-‘Awadi
and Ahmad Al-Jundī. Also Abu Ghudda himself was a member of the
committee selected by the IOMS for reviewing the CIOMS document.46
The whole CIOMS document was reviewed in a uniform way: presenting a selected section of the document followed by the Islamic ethical
framing for that section. The three principles of respect for persons,
beneficence, and justice were introduced in a separate small section
45
46
ʿAwadī and Jundī (2005), op. cit., 150–152.
Ibid., 20.
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Deliberations within the Islamic Tradition on Principle-Based Bioethics 25
(about 300 words in English), exactly as recorded in the CIOMS document. The three principles were introduced as ethical obligations with
equal moral force but that could still be expressed differently and given
different moral weight in varying circumstances. Each principle was
explained in a simple and concise way. Respect for persons entails both
respecting the autonomy of those who are capable of deliberation about
their personal choices and protecting those with impaired or diminished
autonomy. Beneficence is the ethical obligation of maximizing benefits
and minimizing harms. It also implies the prohibition of deliberate infliction of harm on persons, sometimes couched in the term nonmaleficence,
which is counted by some bioethicists like Beauchamp and Childress as a
separate principle. Finally, justice means giving each person what is due
to him or her and thus refers in this context mainly to distributive justice,
which requires the equitable distribution of both the burdens and the benefits although differences can sometimes be justifiable.47 This is how the
question of principles was introduced to the Muslim religious scholars
who were tasked with writing an Islamic ethical review. No reference was
made to the genealogy of these three principles, the socio-cultural context
in which they were born, and their direct link with the Belmont Report.
For instance, the authors of the Belmont Report reiterated its own cultural
context that influenced the process of choosing these specific three principles. Although “other principles may also be relevant,” the authors
conceded, “three basic principles, among those generally accepted in our
cultural tradition, are particularly relevant to the ethics of research involving human subjects: the principles of respect of persons, beneficence, and
justice.”48
With the simplicity by which the three principles were introduced in
a decontextualized way, framing them within the Islamic religioethical
tradition seemed unproblematic. To start with, it was boldly stated that the
overall CIOMS document including the three principles reflect aspects of
a universally shared human nature and common sense whose acceptance
47
Ibid., 150–152.
National Commission for the Protection of Human Subjects of Biomedical and
Behavioral Research (1979). The Belmont Report: Ethical Principles and Guidelines for
the Protection of Human Subjects of Research. Available online via http://www.hhs.gov/
ohrp/humansubjects/guidance/belmont.html (retrieved 10 July 2015), 3–4.
48
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is an Islamic religious obligation. A fourth principle rooted in the Islamic
tradition was tentatively suggested, namely ihsān (moral excellence),
which entails doing more than what is actually required. This principle did
not receive further elaboration in the scholars’ religioethical framing,
which focused more on the three principles. Each of the three principles
was unconditionally endorsed and labeled as one of the established
fundamentals in the eyes of Islamic Sharia (asl muqarrar fī al-sharīʿah
al-Islāmīyah). Embracing the three principles in this almost unprecedented way even within the Instrumentalist Approach has, as tentatively
explained above, to do with the context in which these principles were
introduced to the religious scholars. Here I want to add a few remarks
about the significance of the linguistic aspects and their impact on the
position adopted by these religious scholars. First of all, they have read an
Arabic text in which terms like manfaʿa, maslaha, and darar, as translation for respectively beneficence, welfare, and harm, popped up more than
once. These English terms have specific bioethical connotations, but their
Arabic equivalents have their own juristic connotations within the discipline of Islamic law (fiqh). The religious scholars who worked on the
document approached the Arabic terms as part of the conventional juristic
jargon rather than as translations for terms imported from, and loaded
with, a different context. Thus, the principle of manfa‘a (beneficence) was
understood as part of a deeply-rooted objective in Islamic Sharia, namely
promoting benefits and warding off harms (jalb al-masālih wa dar’
al-mafāsid). However, the benefits to be promoted and the harms to be
averted here, as expounded in the religioethical framing done by the religious scholars, are to be defined and determined by the Sharia itself.49
This perception is not in tune with the understanding of beneficence in the
various works that belong to the genre of bioethics, including the standard
reference of the Belmont Report.
The same remarks can be raised about the religious scholars’ understanding of the term autonomy. It was translated in Arabic as istiqlālīyah
whose more common English equivalent is independence rather than
autonomy. As it appears in the Arabic text, the paragraph on autonomy
speaks about those who can independently (autonomously) take their
49
ʿAwadī and Jundī (2005), op. cit., 158, 160, 161.
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Deliberations within the Islamic Tradition on Principle-Based Bioethics 27
decisions and those whose independence (autonomy) is impaired or
diminished. This way of presenting autonomy made the religious scholars
believe that it has here to do with the juristic concept of legal capacity
(ahlīyah) according to which people are also categorized as those with
complete or incomplete capacity.50 Although there may be a certain overlap between autonomy and ahlīyah, they are definitely not the same thing.
The term ahlīyah is primarily about the competence to fulfill the religious
obligations, which actually can limit the scope of one’s autonomy. This is
why many of the abovementioned authors whose works fall within the
Instrumentalist Approach raised critical remarks about autonomy; they
believed that it may conflict with some religious obligations that Muslims
are bound to follow. Thus, the religious scholars were more engaged in
expounding juristic concepts rooted in the Islamic tradition than engaging
in dialogue with principle-based bioethics. This is even more obvious in
the resolution adopted by the IIFA, which endorsed the four principles
(the three principles in the CIOMS document in addition to the principle
of ihsān) mentioned in the IOMS document. The resolution here was
referring to a document issued by an Islamic organization, viz., the IOMS
and not to the CIOMS document.
2. The Indigenous Approach
2.1. The Pioneering Contribution of the Syrian Religious
Scholar Abu Ghudda
To my knowledge, the earliest study within the Indigenous Approach was
introduced during the Second International Conference on Islamic
Medicine held in Kuwait during the period 29 March–2 April 1982.
During this conference, the Syrian religious scholar Abdul Sattar Abu
Ghudda presented a paper entitled Al-mabādi’ al-Sharʿīyah li al-tatbīb wa
al-ʿilāj (“Sharia-Based Principles for Practicing the Profession of Medicine
and Medical Treatment”).51 The same paper was republished later more
50
Ibid., 159, 160.
ʿAbd al-Sattār Abū Ghuddah (1982). Al-Mabādiʾ al-sharʿīyah li al-tatbīb wa-al-ʿilāj.
Al-Abhāth wa aʿmāl al-muʾtamar al-ʿālamī al-thānī ʿan al-tibb al-Islāmī. Kuwait: Islamic
Medicine Organization & Kuwait Foundation for Advancement of Sciences: 780–792.
51
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than once.52 The content of the paper shows that Abu Ghudda was not
aware of the parallel discussions among Western bioethicists, and it seems
that the question of the possible universality of the principles he proposed
did not preoccupy his mind. As he himself pointed out, Abu Ghudda was
clearly motivated by Islamic religious concerns. In order to achieve their
mission by preserving health and treating diseases, medical professionals
have to employ a number of means, some of which are untraditional and
unusual. By legitimizing the profession of medicine in principle, Islam
does not necessarily legitimize all of the means that medical professionals
are inclined to employ. This is why, Abu Ghudda explained, both physicians and patients should be aware of the (im)permissibility of the means
used in healthcare settings from an Islamic religioethical perspective.
However, the problem is that having in-depth and specialized knowledge
of the Islamic tradition in this field can neither be expected nor required
from every physician. On the other hand, general declarations and codes
will not avail the physicians when they want to apply these general guidelines to the long list of intricate cases they are routinely confronted with
during their work. According to Abu Ghudda, the principle-based
approach is the optimal way to help physicians check the (in)compatibility
of the means they can make use of in their medical tradition with the
Islamic religioethical system without asking too much of them or letting
them fall into the trap of superficial, simplistic, and usually erroneous
applications of the general codes.53
As for terminology, Abu Ghudda clarified that the common term
mabdaʾ (principle) can be accommodated within the Islamic legal discourse. However, Muslim religious scholars usually prefer the equivalent
term qāʿida (rule or maxim), which they have been using throughout the
history of the Islamic tradition to the extent that one can speak about a
distinct genre of Islamic legal maxims (qawāʿid fiqhīyah). In order to
underscore the significance of this genre, Abu Ghudda quoted the prominent Mālikī jurist Shihāb al-Dīn al-Qarāfī (d. 1285) who argued that fundamentals of Sharia can be divided into two main categories, namely
52
ʿAbd al-Sattār Abū Ghuddah (1983). Al-Mabādiʾ al-sharʿīyah li al-tatbīb wa-al-ʿilāj,
Al-Muslim al-Muʿāsir 9(35): 105–115; ʿAbd al-Sattār Abū Ghuddah (1994). Al-Mabādi
al-sharʿīyah li al-tatbīb wa-al-ʿilāj. Majallat Majmaʿal-Fiqh al-Islāmī al-Dawlī 8(3): 129–146.
53
ʿAbd al-Sattār Abū Ghuddah (1982), op. cit., 780, 781.
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Deliberations within the Islamic Tradition on Principle-Based Bioethics 29
fundamentals of the legal theory (usūl al-fiqh) and the grand legal maxims
(al-qawāʿid al-fiqhīyah al-kullīyah). Abu Ghudda composed a list of 23
principles and conceded that the list is by no means comprehensive. His
target was to select only those principles with direct relevance to the field
of medical ethics. He grouped this long list of principles under five main
clusters, namely (i) the concept of benefit or interest (maslaha) which
included two principles; (ii) avoiding harms and removing them, which
included eight principles; (iii) removing hardship and considering the cases
of necessity, which included eight principles; (iv) the right of the other and
the necessity of obtaining consent, which included three principles; and
(v) cooperation, usefulness, and altruism, which included two principles.54
The pioneering study of Abu Ghudda did open important windows for
thinking about how to develop a principle-based bioethics rooted in the
Islamic tradition. As we shall see in this volume, his approach of employing the genre of Islamic legal maxims (qawāʿid fiqhīyah) for developing
principles proved to be appealing for various religious scholars who participated in the CILE seminar. However, Abu Ghudda’s contribution
remained considerably limited in scope by focusing almost exclusively on
Islamic law (fiqh) and particularly on one branch within fiqh, namely the
genre of legal maxims. Other disciplines within the Islamic tradition like
Islamic theology, higher objectives of Islamic Sharia (maqāsid al-sharīʿah),
and their possible contribution to developing a theory of Islamic principlebased biomedical ethics were almost completely missing. Also, a principle-based theory in bioethics cannot be developed by just enlisting a set
of principles. It is indispensable to address other interrelated issues like
moral theories, moral virtues,55 and moral status of individuals, which
were all missing in Abu Ghudda’s study.
2.2. The Contributions of Abdulaziz Sachedina
The first encounter between the Instrumentalist and the Indigenous
Approaches took place more than a decade after the publication of Serour’s
54
Ibid., 782–791.
For example, Amyn Sajoo (2014). Negotiating virtue: Principlism and Maslaha in
Muslim bioethics. Studies in Religion 43(1): 53–69.
55
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pioneer study. Like its first edition, which included the contributions of
Serour and Hasan, the second edition of the edited volume Principles of
Health Care Ethics, published in 2007, also included a chapter on the
Islamic tradition.56 This chapter was written by Abdulaziz Sachedina, the
then Frances Myers Ball Professor of Religious Studies, University of
Virginia and now the International Islamic Institute (IIIT) Chair in Islamic
Studies, George Mason University. Two years later, Sachedina addressed
the same issue in much more detail in his book Islamic Biomedical Ethics:
Principles and Application. As is clear from its subtitle, the issue of principles represented a focal theme that was recurrently examined throughout
the whole book, but it was addressed separately in the longest chapter of
the book, “In Search of Principles of Healthcare Ethics in Islam.”57
Because of the substantial overlap between the two studies, I will present
Sachedina’s ideas as outlined in both works interchangeably and will refer
specifically to one of the two studies only when necessary.
Out of all the abovementioned studies, Sachedina was only aware of
the two pioneering studies done by Gamal Serour and K. Hasan. He argued
that the contributions made by both of them, published in the first edition
of Principles of Health Care Ethics, failed to provide uniquely Islamic
principles of bioethics mainly because of a twofold reason. On one hand,
they did not assess the intellectual context, particularly the secular and
democratic political philosophy, of the four principles that informs much
of the principle-based bioethics in the West.58 On the other hand, these
56
Abdulaziz Sachedina (2007). Islam and the four principles, in Richard Ashcroft et al. (eds.)
Principles of Health Care Ethics, 2nd edn. London: John Wiley & Sons Ltd: 117–125.
57
Abdulaziz Sachedina (2009). Islamic Biomedical Ethics: Principles and Application.
Oxford: Oxford University Press: 25–75.
58
The proposition that the four principles are essentially the product of secular Western or
more particularly American culture rather than having a universal character has been reiterated by various voices within the field of Islamic bioethics (e.g. Atighetchi (2007), 22;
Jafarey and Moazam (2010), 353, 360). Some Western physicians, with no Islamic studies
background, also expressed their doubts about the supposed cultural neutrality of the four
principles (e.g. Westra et al. (2009), 1383–1387). See: Dariusch Atighetchi (2007). Islamic
Bioethics: Problems and Perspectives. Dordrecht, the Netherlands: Springer; Aamir Jafarey
and Farhat Moazam (2010). ‘‘Indigenizing’’ bioethics: The first center for bioethics in
Pakistan. Cambridge Quarterly of Healthcare Ethics 19: 353–362; Anna Westra, Dick
Willems and Bert Smit (2009). Communicating with Muslim parents: “The Four Principles”
are not as culturally neutral as suggested. European Journal of Pediatrics 168: 1383–1387.
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Deliberations within the Islamic Tradition on Principle-Based Bioethics 31
contributions did not elaborate on the presuppositions of the Islamic tradition about human action, its ontology, and its ethical evaluation and about
the roles of moral reasoning and scriptural sources in addressing practical
ethical dilemmas. This happened, Sachedina explained, because the two
authors lacked adequate training in the Islamic legal sciences, without
which one cannot identify the principles and the rules that Muslim jurists
use to justify and assess moral–legal decisions within their own cultural
environment.59
In order to repair the deficiencies of these two studies, Sachedina
dedicated a substantial part of his works to examining a number of methodological issues related to Islamic moral epistemology and ontology.
He spoke about the attempts of Muslim religious scholars throughout
Islamic history to keep the balance in their ethical reasoning between
scripture- and reason-based sources. This balance was required to avoid
excessive literal reading of the scriptures that may negatively affect the
adaptability of Islamic law to meet the changing needs of society. On the
other hand, this balance was also needed to avoid possible arbitrary judgments of reason. Furthermore, Sachedina discussed the problem of situating the credible religious authority empowered to sanction specific modes
or conclusions of religioethical reasoning. It did not escape Sachedina in
his quest for exploring “distinctly Islamic, and yet cross-culturally communicable, principle-rule based deontological–teleological ethics” to
show that the Western-American set of four principles does have some
features that can hardly fit within the Islamic tradition. His critique for the
principle of autonomy serves as a representative example in this regard.
Sachedina said that the highly rated principle of autonomy in the West will
not enjoy the same status within the Islamic tradition, which gives higher
priority to communitarian ethics when the consequence of a medical decision on the family and community resources should be seriously considered. Thus, Sachedina argued, the dominant principle of autonomy, which
is based on liberal individualism, should be substituted by the rule of
consultation (shūrā), which is an indigenous part of Islamic ethics.60,61
59
Sachedina (2007), op. cit., 117; Sachedina (2009), op. cit., 26, 27.
Sachedina (2007), op. cit., 118, 122; Sachedina (2009), op. cit., 30–45.
61
The Ph.D. dissertation “Beyond Clerics and Clinics: Islamic Bioethics and Assisted
Reproductive Technology in Iran” written by Robert Tappan and supervised by Sachedina,
60
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Sachedina introduced two main broad principles, namely common
good (maslaha) and “no harm, no harassment” (la darar wa la dirār).
According to him, these two principles are deeply rooted in the Islamic
tradition and their ascription to the authoritative Islamic sources is undisputed. On the other hand, Sachedina argued that these two principles are
flexible enough to accommodate and address the new ethical issues in the
modern field of healthcare. He gave the example of the ethical issues
raised by prenatal genetic diagnosis (PGD) and how the principle of common good can help resolve them. He also explained how the principle of
“no harm, no harassment” can help addressing some end-of-life ethical
issues like (not) using life-support machines for terminally ill patients.
According to Sachedina, this principle is at the heart of the ethical deliberations around almost 90 percent of cases confronting people working in
the healthcare sector in the Muslim world.62
The two contributions of Sachedina, besides the above-mentioned
work of Abu Ghudda, demonstrate the appeal of the genre of Islamic legal
maxims (qawāʿid fiqhīyah) to those who search for principle-based bioethics stemming from the Islamic tradition.63 Whereas Sachedina introduced two main principles, Abu Ghudda introduced five clusters of
principles each of which included a number of subprinciples or legal
maxims. Also the UK-based Muslim physician Yassar Mustafa has
recently made use of the same genre to articulate five principles (qasd
(intention), yaqīn (certainty), darar (injury), darūra (necessity), and ‘urf
demonstrated the validity of this argument as far as the bioethical deliberations on Assisted
Reproductive Technology (ART) in Iran are concerned (Tappan 2011, 38, 71). See Robert
Tappan (2011). Beyond Clerics and Clinics: Islamic B ioethics and Assisted Reproductive
Technology in Iran. Dissertation presented to the Graduate Faculty of the University of
Virginia in Candidacy for the Degree of Doctor of Philosophy.
62
Sachedina (2007), op. cit., 121–124; Sachedina (2009), op. cit., 49–75.
63
Aziz Sheikh and Abdul Rashid Gatrad (2001). Medical ethics and Islam: Principles and
practices. Archives of Disease in Childhood 84: 75; Kamel Ajlouni (2003). Values, qualifications, ethics and legal standards in Arabic (Islamic) medicine. Saudi Medical Journal
24(8): 820–821; Aida Al Aqeel (2007). Islamic ethical framework for research into and
prevention of genetic diseases. Nature Genetics 39(11): 1295–1297; Bagher Larijani and
Farzaneh Anaraki (2008). Islamic principles and Decision Making in Bioethics. Nature
Genetics 40(2): 123; Hamza Yusuf Hanson (2008). In Aziz Sheikh and Abdul Rashid
Gatrad (eds.) Caring for Muslim Patients. Oxford, NY: Radcliffe: 47–49.
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Deliberations within the Islamic Tradition on Principle-Based Bioethics 33
(custom), each of which revolves around a number of legal maxims.64
Throughout this volume, we will also see that the religious scholars who
participated in the CILE seminar advocated this approach, although they
did not come to a clear conclusion about which maxims should be selected
and which selection criteria should be employed. Thus, making benefit of
the genre of Islamic legal maxims seems promising, but a lot of work
should still be done. The engagement of these authors with the principlebased approach of bioethics remains minimal. This holds true even to
Abdulaziz Sachedina, who is well aware of the four-principle approach
developed by Beauchamp and Childress (the latter wrote a foreword for
Sachedina’s book). Despite his serious efforts to introduce two “distinctly
Islamic yet metaculturally communicable” principles, Sachedina said
almost nothing about how similar/different these two principles are in
comparison with the two principles of beneficence and nonmaleficence.65
Furthermore, the term justice and its derivatives appeared more than 70
times throughout Sachedina’s book, and it was sometimes used alongside
the principle of common good or public benefit to determine the ethical
weight of specific biomedical interventions.66 However, the author did not
explain why justice was not categorized as a distinct bioethical principle.
3. Concluding Remarks: The Unfinished Task
All the studies reviewed in this chapter reflect a kind of consensus among
experts in Islamic bioethics about the uncontested benefit of having a set
of principles that governs this emerging field in order to secure a certain
degree of conformity and coherence. However, these experts have disagreed on how to formulate this set of principles. The diverging opinions
on this question were divided in this study into two main approaches,
namely Instrumentalist Approach and Indigenous Approach, each of
which has its own characteristics, strengths, and weaknesses. By the end
of this section, a tentative proposal for a hybrid approach is presented as
a possible research agenda for the future.
64
Yassar Mustafa (2014). Islam and the four principles of medical ethics. Journal of
Medical Ethics 40: 480.
65
Sachedina (2009), op. cit., 65, 66.
66
Ibid., 170.
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The Instrumentalist Approach, almost monopolized by biomedical
scientists trained in Western academies,67 proved to be more productive,
quantitatively speaking, than the other approach. One of the common
convictions shared by the advocates of this approach is that the principles
outlined in Western bioethical literature, especially the four principles of
Tom Beauchamp and James Childress, are universal and transcultural in
nature. Thus, their compatibility with the Islamic tradition is taken by
default and all what these advocates have been trying to do is to “reveal”
or “unearth” this compatibility for their audiences. Their main instrument
for achieving this task is quoting Islamic authoritative texts, especially
from the Qur’an and Sunna. The proponents of this approach also showed
common interest in building bridges between Islam and the West. In a bid
to demonstrate that the Islamic tradition is not always the passive partner
that receives what Western bioethics has produced, some of these advocates argued, usually in an apologetic tone, that the principles articulated
by contemporary Western bioethicists have already existed for centuries
in the works of pre-modern Muslim religious scholars. The principles
introduced by Western bioethicists were not equally embraced by all the
advocates of this approach. Whereas some of them almost unconditionally
accepted all principles, many of them expressed reservations about specific principles. The principle of respect for autonomy seems to be the
most controversial one to the extent that some researchers spoke about
“Islamic autonomy” versus a “Western type of autonomy” with significant
differences between the two versions of autonomy. Also some authors
suggested adding some principles, in their view uniquely Islamic in
nature, to the list articulated by Western bioethicists.
67
Available studies show that this generalization holds true for physicians with both Sunni
and Shīʿī backgrounds. Although most of the contributions reviewed in this study
expressed Sunni perspectives, contributions made by physicians with Shīʿī backgrounds
echo almost identical thoughts with quotations from figures or sources acclaimed in the
Shīʿī tradition. See for example: Kiarash Aramesh (2008). Justice as a principle of Islamic
bioethics. The American Journal of Bioethics 8(10): 26–27; Shabih Zaidi (2014). Ethics in
Medicine. Dordrecht, the Netherlands: Springer: 75–99. The work of the Dutch convert
Abdulwahid van Bommel, who worked as Muslim chaplain and imam, can also be categorized within the Instrumentalist Approach. See A. van Bommel (1999). Medical ethics
from the Muslim perspective. Acta Neurochirurgica Supplements 74: 18–21.
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Deliberations within the Islamic Tradition on Principle-Based Bioethics 35
The main strength of the Instrumentalist Approach is its dependence
on a well-structured and coherent theory that managed to gain wide
international recognition although its birth was in an exclusively
Western or even particularly American context. The feasibility of the
principle-based theory to address different bioethical dilemmas has
been amply proved. Because of the strong appeal of this theory among
biomedical scientists and bioethicists worldwide, its “Islamized” version, the advocates of this approach believe, would do a good service to
the Islamic tradition by making their contribution an integral part of the
global bioethical discourse. On the other hand, the main weakness of
this approach is the lack of sophisticated discourse and sometimes even
the use of superficial arguments and hasty conclusions. This holds true
for their understanding of, and explanation for, the principle-based
theory but becomes more flagrant when they try to demonstrate the
compatibility of specific principles with the Islamic tradition. The advocates of this approach also hardly say anything about how these principles can be applied within the religioethical framework of the Islamic
tradition. One of the chronic problems of the principle-based theory is
the so-called process of “specification” or how to downstream these
broad principles and apply them to particular case studies. The principle
of beneficence can serve as a good illustrative example here. By adopting this principle, which implies doing all possible efforts to achieve the
benefit of the patient, the central question will be: What makes a certain
medical intervention a benefit? This used to be the estimation of the
physician (Hippocratic paternalistic model), but in contemporary
Western bioethical discourse, this should be the patient’s discretion and
the physician is exclusively entitled to provide the patient with information (informative model). However, in the Islamic religioethical tradition, “benefit” is to be determined in the first instance by God, and what
contradicts God’s ordinances cannot be considered beneficial even if it
is demanded by both the patient and the physician. Thus, endorsing a set
of principles will not guarantee uniformity in bioethical reasoning as
long as the process of specification is also fine-tuned, and this cannot
be done anyhow without a more in-depth understanding of the Islamic
tradition.
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As for the Indigenous Approach, the pool of its advocates consists
mainly of religious scholars and specialists in Islamic studies,68 and their
scholarly output is, quantitatively speaking, still modest. The advocates of
this approach share the strong conviction that the Islamic tradition is rich
enough to produce a set of indigenous and homegrown principles that can
enrich the contemporary field of bioethics. They are also much more
concerned about demonstrating the viability of the Islamic tradition
in modern times and protecting its identity than building bridges with
other traditions. Their engagement and interaction with principle-based
theories is minimal, and some of the advocates of this approach are simply
unaware of such theories.
The main strength of the Indigenous Approach is the depth of the
Islamic religioethical discourse introduced by its advocates, which far
exceeds what we come across in the publications of the Instrumentalist
Approach. This explains the existence of a common conviction shared by
the advocates of this approach that their discourse should be more appealing for Muslim individuals and communities. Thus, unlike the proponents
of the Instrumentalist Approach, they do not feel obliged to defend the
“Islamic character” of their approach or its compatibility with the Islamic
tradition. On the other hand, the main weakness of the Indigenous
Approach is that its advocates hardly engage in serious dialogue with the
principle-based bioethical discourse developed within the Western
tradition. The product of principle-based bioethics or principlism, whose
theorists have been working for decades, is not just a list of principles but
a full-fledged theory or even a number of related theories. Had they studied these theories properly, the proponents of this approach would have
68
One of the few exceptions that I am aware of is an article published in 2001 by two
Muslim UK-based physicians, namely A. R. Gatrad and A. Sheikh. They both expressed
their dissatisfaction with the call for having universal ethical codes and proposed what
they called an alternative approach, which focused on the particularity of the Islamic
tradition. They included a considerably heterogeneous list of principles drawn from
Qur’anic verses, prophetic traditions, Islamic legal maxims, and quotations from the
works of Muslim writers. It is clear that the main target of Gatrad and Sheikh was to
simplify Islamic bioethics for the non-Muslim physicians working in the UK rather than
to develop a principle-based Islamic bioethical discourse (Sheikh and Gatrad 2001,
72–75). See Aziz Sheikh and Abdul Rashid Gatrad (2001). Medical ethics and Islam:
Principles and practices. Archives of Disease in Childhood 84: 72–75.
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Deliberations within the Islamic Tradition on Principle-Based Bioethics 37
been able to go beyond the debate on which list of principles is more
compatible with Islam. The sophisticated debates on the methodological
and analytical tools of principlism would have helped them produce parallel principle-based theories rooted in the Islamic tradition rather than just
a list of principles. Also, the advocates of this approach focused almost
exclusively on the genre of Islamic legal maxims (qawāʿid fiqhīyah).
Although this genre proved promising for producing bioethical principles
rooted in the Islamic tradition, future studies should also explore the possible contribution of other genres and disciplines like the higher objectives
of Islamic Sharia (maqāsid al-sharīʿah), Islamic theology, and spirituality.
Bearing in mind the characteristics, strengths, and weaknesses of
each of these two approaches, this edited volume presents the seed for,
and foretells the features of, a hybrid and more elaborated approach
whose realization still awaits more research in the future. Below, we highlight the main features of this proposed approach that takes into consideration the positive and negative aspects of the two approaches reviewed
in this chapter.
Producing a coherent theory claimed to be rooted in the Islamic tradition necessitates broadening our understanding of what the Islamic tradition actually is. Besides the genre of Islamic legal maxims, the proceedings
of the CILE seminar did open new windows for exploring new horizons.
For instance, the paper of Sheikh Ahmed Raissouni showed the relevance
of the genre of virtues (fadāʾil or makārim), the paper of Sheikh Abu
Ghudda examined the relevance of the long-standing genre of adab
al-tabīb (practical ethics of the physician), and the paper of Sheikh Ali
al-Qaradāghī explored the vast genre of the higher objectives of Sharia
and its possible interrelatedness with the genre of legal maxims. All these
terrains will need much more research in the future as well.
On the other hand, serious and critical engagement with the principlebased theories articulated by Western bioethicists is indispensable. These
theories have found their way to the overwhelming majority of physicians
worldwide and, as we have seen in this chapter, those of Muslim
background were no exception in this regard. The first ever face-to-face
discussions between Tom Beauchamp and Muslim religious scholars during the CILE seminar was a significantly enriching element that surely
necessitates many more steps in this direction in the future. However,
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researchers should be mindful that principle-based bioethics is broader
than the works of Beauchamp and Childress. Other contributions made by
individuals like the renowned American bioethicist Robert Veatch,69 by
international organizations like UNESCO,70 and by theologians from religious traditions like Catholicism71 should also be studied. Furthermore,
engagement with principle-based theories should not be confined to
checking their compatibility with Islam as if these theories make part of a
“Holy Scripture” of Western bioethics. Engagement with these theories
should be critical towards these theories as they stand. As an attempt to
fill in this gap, this volume includes a chapter written by the Dutch
bioethicist, Annelien Bredenoord, on the arguments for and against principlism within the Western bioethical discourse. Muna Ali’s chapter in this
volume also strongly argues for the point that future bioethical discourse
should be critical not only of the religioethical traditions but also to our
understanding of the profession of medicine itself.
Finally, no full-fledged theory of bioethics can be realized without
paying due attention to metaethics, the branch of ethics that addresses
questions about the source of ethics and morals and how they can be
justified or reasoned. As the reader will observe, a great deal of the
deliberations during the CILE seminar had to do with the role of religion
in producing “universal” bioethical principles. Is it possible to produce
universal principles with(out) serious engagement with religion? Does a
certain set of principles become “Islamic” only when they originate from
the Islamic tradition itself or also whenever these principles are in tune
with its spirit? To think a bit outside the box, we also need to address
questions like: Does the principle-based model represent the optimum
model for guaranteeing coherence and consistency in the Islamic bioethical discourse? Is it possible to guarantee similar, or maybe even
stronger, levels of coherence and consistency by employing specific
69
Robert Veatch (2012). Basics of Bioethics, 3rd edn., Boston: Pearson Education, Inc.,
47–143, 164–179.
70
Henk Ten Have and Michèle Jean (eds.) (2009). The UNESCO Universal Declaration
on Bioethics and Human Rights: Background, Principles and Application. Paris: United
Nations Educational, Scientific and Cultural Organization.
71
Scaria Kanniyakoni (2007). The Fundamentals of Bioethics: Legal Perspectives and
Ethical Approaches. Kottayam, India: Oriental Institute of Religious Studies: 268–328.
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Deliberations within the Islamic Tradition on Principle-Based Bioethics 39
aspects of the discipline of Islamic legal theory (usūl al-fiqh), which has
been used for centuries to address complicated religioethical issues from
an Islamic perspective? This volume is meant to provide researchers
with provocative intellectual foodstuff so that they may conduct more
research on such questions and their relevance for principle-based bioethics, surely an enduring task for researchers in this emerging field for
years to come.
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The “Bio” in Biomedicine:
Evolution, Assumptions,
and Ethical Implications
Muna Ali
Abstract: As biomedicine and its research and technologies globalize, they
are accompanied by Principlism, the dominant Western bioethical theory. The
Muslim response has roughly taken two tracks: (i) criticism of principlism as a
neo-imperialistic attempt to universalize what is specific or (ii) harmonization
of principlism with Islam by showing not only that the four principles
(autonomy, beneficence, nonmaleficence, and justice) are universal, but that
indeed Islam had, long ago, codified them in its ethico-legal tradition. In these
debates, medicine and biomedicine are conflated and bioethics is reduced
to principlism. This is problematic because biomedicine is but one medical
system and principlism is one among several (feminist, religious, narrative,
global) theories. This chapter examines some of the relevant critical questions
to bring insights from the philosophy, anthropology, and sociology of medicine
and of bioethics to bear on the current discussion on Islam and bioethics
and the questions posed by the research Center for Islamic Legislation and
Ethics (CILE).
Muslim scholars and medical professionals have grappled with pressing
ethical issues (abortion, in-vitro fertilization, end-of-life issues, and organ
donation/transplantation presented by the advances in biomedicine and
tried to offer guidance to Muslim practitioners, patients, and policy makers.
Their ethico-legal response to these questions and efforts to engage the
41
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dominant Western bioethical theory (principlism)1 have contributed to an
“Islam and medical ethics” discourse, though an “Islamic bioethics”
theoretical framework is yet to emerge.
As biomedicine and its research and technologies globalize, they are
accompanied by the principlism theory of bioethics. The Muslim response
has, more or less, taken two tracks: (i) criticism of principlism as a neoimperialistic attempt to universalize what is specific and rooted in Western
philosophical tradition and historical context or (ii) harmonization of
principlism with Islam by showing not only that the four principles
(autonomy, beneficence, nonmaleficence, and justice) are universal, but
that indeed Islam had, long ago, codified them in its ethico-legal tradition.
Both positions also reference the “ethics of the physician” to elaborate a
framework for Islamic medical ethics. In these debates, medicine and
biomedicine are conflated and bioethics is reduced to principlism. This is
problematic because biomedicine is but one medical system and principlism is one among several (feminist, religious, narrative, global) theories
to address the moral conundrums presented by biomedicine.
The virtues and failings of biomedicine and principlism are more frequently debated within the West itself. It is critical that Muslim religious
and medical experts acquire expertise and contribute to these debates in
order to adequately address emerging biomedical ethical questions and for
Islamic moral reasoning and ethical theory to have any relevance in the
contemporary world. To do so, upstream from the urgent biomedical
issues or the critique of “Western bioethics,” what is needed is a deep
reflection and rigorous examination that begins with the critical interrogation of foundational concepts. What is “biomedicine,” and what historical
trajectory resulted in the prefix “bio”? What does that reveal and conceal
about underlying moral positions and values and epistemological and
metaphysical assumptions about how we know what we know and what
is “real”? How does biomedicine conceptualize the human being, the
1
Beauchamp and Childress (1979) detail their four principles (autonomy, benevolence,
nonmaleficence, and justice) theory in their seminal book Principles of Biomedical Ethics
(1979). The term Principlism was coined by Clousser and Gert in their 1990 critique of
this theory in an article titled “A Critique of Principlism” published in the Journal of
Medicine and Philosophy 15: 219–236. It has since become a more neutral term and shorthand for Beauchamp and Childress’s theory.
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The “Bio” in Biomedicine 43
body, and the relationship of self with others and with nature? What
meanings and understandings of health, illness, life, and death guide the
research and practice of biomedicine and biotechnologies? This chapter
aims to examine these critical questions and others to bring insights from
the philosophy, anthropology, and sociology of medicine and of bioethics
to bear on the current discussion on Islam and bioethics and the questions
posed by the research Center for Islamic Legislation and Ethics.
1. Biomedicine: A Brief History
Healers (shamans, bonesetters, etc.) attending to human ills have always
existed in every culture. Complex medical systems such as Chinese,
Ayurvedic, and Unani medicines are still practiced.2 The Hippocratic Oath
remains the foundation of medical ethics today. Medieval Muslim physicians, mastering both religious and medical sciences, made lasting contributions to medicine, and Ibn Sina’s (Avicenna) The Cannon of Medicine
remained the primary textbook at Western universities until the 17th
century. Many of his concepts and theories are still present in modern
medicine. Today, Muslims engaging the discourse on bioethics invoke this
history and the centuries-old code of ethics for physicians developed by
Al-Ruhawi and Al-Razi.3 However, the medicine practiced then is not the
biomedicine of today. While traditional medicine maintains the connection of patients with their spiritual, physical, and social realms, biomedicine has not only severed these relationships, but other entities (the state,
insurance companies, and medical facilities administrators) now mediate
the patient–physician relationship in what has been termed the “medical–
industrial complex.”4
2
Chinese medicine and Ayurvedic Indian medicine are gaining cosmopolitan status as they
spread outside China and India. Unani medicine remains mostly in the Middle East and
South Asia and links Muslim medicine with Greek medicine and Hippocrates who is
referred to as the father of medicine.
3
Aasim I. Padela (2007). Islamic medical ethics: A primer. Bioethics 21(3): 169–178.
PBS, Frontline (2001). Organ Farm. Available online via http://www.pbs.org/wgbh/pages/
frontline/shows/organfarm/ (retrieved 1 July 2013).
4
Raymond De Vries (2011). The uses and abuses of moral theory in bioethics. Ethic
Theory Moral Practice 14: 424.
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Medicine in the West changed drastically with the advent of the
scientific revolution of the 17th century when dissection enabled an “anatomical gaze resulting in the objectification of bodies.”5 By the 19th century, population studies generated statistical data on group-based biological
features leading to the development of “norms” to which individual bodies
could be compared.6 With this, a universalized human body emerged: a
biological entity responding to disease in the same way everywhere. This
launched the development of biomedicine.7 Often simply called “medicine,” the dominant contemporary medical system is variously referred to
as “modern medicine,” “Western medicine,” or “allopathic medicine.”
Calling it only “medicine” deems other long-established medical systems
simply “folk” practices based on “belief” and not on “knowledge.”8,9
Consequently, the term “biomedicine” has been coined to distinguish “the
body of knowledge and associated clinical and experimental practices
grounded in medical sciences that were gradually consolidated in Europe
and North America from the 19th century on.”10 This is a technologybased medical system consisting of an “assemblage of activities” in physicians’ offices, hospitals, research centers, and elsewhere which is ever
5
Margaret Lock and Vinh-Kim Nguyen (2010). An Anthropology of Biomedicine. Chichester,
West Sussex: Wiley-Blackwell: 27.
6
As the state embarked on the double task of modernization and imperial expansion, it
needed a healthy work force and ways of managing populations at home and in the colony
and thus created the infrastructure for the statistical studies of large populations and for
ever more complex clinic laboratory work. (Harold Vanderpool (2008). The religious
features of scientific medicine. Kennedy Institute of Ethics Journal 18(2): 82.)
7
Lock and Nguyen (2010), op. cit.
8
The study of Biomedicine as one among several medical systems was a later development. Social scientists considered Western medicine the standard medical system, presumably scientific and therefore unbiased and above the effect of culture, against which all else
was measured and deemed to be “cultural” or folk healing practices. This not only
dismissed any scientific grounding for the other systems but it also “stripped the illness
experience of its local semantic content and context” (Gaines and Davis-Floyd (2004), 96).
It was only in the past 30 years that closer examination of biomedicine as a Western
“ethnomedicine” began to challenge Biomedicine’s monopoly over authoritative knowledge. See Atwood Gaines and Robbie Davis-Floyd (2004). Biomedicine, in Melvin Ember
and Carol Ember (eds.), Encyclopedia of Medical Anthropology, Dordrecht, Netherlands:
Kluwer Academic Publishers.
9
Gaines and Davis-Floyd (2004), op. cit.
10
Lock and Nguyen (2010), op. cit., 365.
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more connected with “global capital.”11 The prefix “bio” indexes the
centrality of biological and other natural sciences and ontological and
epistemological assumptions undergirding this dominant system.
2. The Social Construction of the Body
and of Knowledge
Enlightenment ideas about nature, human being, progress, and knowledge
shaped the sciences upon which biomedicine is built.12 The emergence of
physics’ universal laws that explain how nature works inspired efforts
to similarly formulate universal biological laws that govern organisms
including the human body and what ails it. The body is assessed through
standardized processes and compared to “norms,” and the generated knowledge and associated technologies and ways of thinking are to be spread
globally.13 Biological sciences have contributed greatly to our understanding of the human body. The knowledge produced is real, but rather than
being “different representations of the same ontological reality — the universal body,” these insights are more “snapshots” by “lenses onto a shifting
and contingent reality.”14,15 Advances in molecular biology now challenge
the assumption of a “normal” biological body against which all differences
are measured and deemed “abnormal”16 and affirm that bodies are products
of their physical–social–historical contexts. Likewise, the knowledge about
this body emerges from technologies of particular socio-cultural contexts.
The questions asked, what is knowable, and how knowledge is interpreted
emerge not from a detached observer aiming for universal knowledge, but
from a local context and have political implications.17
11
Ibid.
Ibid.
13
Ibid., 20.
14
For example, a human fetus is a real entity but, as Barad argues, is one that we come to
know through medical imaging technology that renders the mother invisible and represents
the fetus as a “self-contained, free floating object under the watchful eye of scientific and
medical surveillance” (Lock and Nguyen (2010), op. cit., 94) whose fate and rights are
contentiously debated.
15
Lock and Nguyen (2010), op. cit., 93.
16
Ibid.
17
Ibid.
12
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Biomedicine is unique among other medical systems in its “systematic
approach to objectifying, classifying, and quantifying the human body
itself assumed to be derived from a universal template.”18 Biomedicine,
like modern science, cannot be disentangled from the historical and sociocultural context from which it emerged. Both are steeped in unexamined
assumptions and neither is culture or value neutral.19 Additionally, technologies are not mere application of knowledge; they also serve as instruments and methods in the production and practice of knowledge.20 Social
scientists and philosophers have illustrated that how we perceive nature in
many ways reflects our cultural understandings and worldview. As Gaines
and Davis-Floyd pointed out, each medical system has these cosmological
understandings and assumptions at its foundation.21 Claims that biomedicine is unencumbered by belief and cultural values would make it an
oddity among medical systems.22
18
Harold Vanderpool (2008). The religious features of scientific medicine. Kennedy
Institute of Ethics Journal 18(2): 203–234.
19
No human endeavor is free from the tacit cultural beliefs and values or power relations
within which one is immersed, and biomedicine is no exception. Biomedical knowledge
and practices reflect cultural norms and inequalities based on gender, class, ethnicity, or
race and at times reinforce them by giving them “scientific” cover and medicalization.
Additionally, the knowledge and classification of illness (for example, HIV–AIDS) are the
products of the socially constructed, contested, and negotiated by diverse players (physicians, scientists, pharmaceutical companies, activists, and policy makers) and not so much
the result of “pure” science and research (Conrad (2010)). See Peter Conrad and Kristin
K. Barker (2010). The social construction of illness: Key insights and policy implications.
Journal of Health and Social Behavior 51: S67–S79.
20
Lock and Nguyen (2010), op. cit.
21
Gaines and Davis-Floyd (2004), op. cit.
22
Biomedicine’s values and beliefs include what Gaines and Davis-Floyd (2004) have
referred to as “the myth of technocratic transcendence” where technology is believed to
be the panacea for all that ails or limits humans physically, cognitively, or even socially.
Often religion and sciences are framed in opposition, and religious discourse is assumed
to be based on beliefs without critical thinking: “What is interesting here is that those who
most decry the alleged moral certitude of religious believers and other strong moral
evaluators are themselves awash in unyielding certitude that manifests itself in not taking
seriously the arguments of those they oppose” (Elshtain (2008), 167). As much as biomedicine distances itself from religion by privileging empirical knowledge, devaluing
intuitive and revealed knowledge, and disregarding patients’ religious beliefs, Gordon
(1988) pointed out the religious-like features of biomedicine and biomedicine cosmology
in its view of nature as neutral, its neglect of human relations, and its bio-reductionist
approach to illness. Biomedicine is seen as scientific because it relies on evidence for
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The “Bio” in Biomedicine 47
Disease and illness are often considered interchangeable notions, and
health is understood as a disease-free state. However, one could be ill and
unhealthy without having a disease. Disease is a formal category within
medical systems while illness captures how disease is experienced and
given meaning within a particular socio-cultural context. Health, according
to the World Health Organization, is a state of mental, physical, spiritual,
and social well-being and not the mere absence of disease.23 The categorizations and meanings of illness are embedded in local socio-cultural contexts which determine how it is viewed, diagnosed, and treated and what
resources are allocated to it. Illness is a social and not merely biological
reality. Ethnographic studies have demonstrated the cultural differences in
the understanding and experience of pain and of conditions such as HIV
and AIDS. There are conditions that are culturally specific (for example,
anorexia in the West, Zar in the Middle East, Kuru in Guinea) and classified as “culturally bound syndromes.” This social construction of illness
becomes most evident in the process of medicalization of behavior (alcoholism, malnutrition, anxiety, hyperactivity, and recently obesity) and of
female biological functions (menstruation, pregnancy and childbirth, and
diagnosis and treatment, but the practice of biomedicine is not “a science” like physics;
though, as noted earlier, many insights from physics have been extended to medicine. This
is because even as it purports to “discover” diseases, these are socio-culturally constructed
and informed by a societal ethos, economics, and politics (Gordon (1988)). Furthermore,
while it rationally and objectively is in counterdistinction to religious belief and subjectivity, it cannot block patients’ and practitioners’ worldviews from informing the clinical
encounter. Its religious-like features include its “promises of rescue and salvation, and its
ever-increasing guardianship over human life” (Vanderpool (2008), 224). These features
notwithstanding, biomedicine is non-religious and technology-based and has as its central
metaphor the body as machine. Consequently, practitioners aim to cure, as in “to fix
malfunctions,” and not to heal, as in “the long-term beneficial changes in the whole
somatic–interpersonal system,” which results in neglecting the psycho-spiritual-socialenvironmental aspect of health (Kirmayer (2004), 46). See Gaines and Davis-Floyd (2004),
op. cit.; Jean Bethke Elshtain (2008). Why science cannot stand alone. Theoretical
Medicine and Bioethics 29: 161–169; Deborah, Gordon (1988). Tenacious Assumptions in
Western medicine, in M. Lock and D. Gordon, (eds.), Biomedicine Examined Dordrecht:
Kluwer Academic Publishers; Vanderpool (2008) op. cit.; Kirmayer, Laurence J. (2004).
The cultural diversity of healing: Meaning, Metaphor and Mechanism. British Medical
Bulletin 69: 33–48.
23
World Health Organization definition of health. Available online via http://www.who.
int/about/definition/en/print.html (retrieved 20 July 2013).
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menopause) which now require monitoring and interventions.24 Similarly,
a growing pursuit of physical enhancements through drugs (Viagra, growth
hormone, etc.) and cosmetic surgeries to sculpt the body to fit an idealized
body is also indicative of the medicalization process.25
Metaphors are also an important aspect of the social construction of
illness. Metaphors are not mere linguistic embellishment but are important
tools for conceptualization. They are “epistemological device[s], serving to
conceptualize the world, define notions of reality, and construct
subjectivity.”26 Metaphors do powerful cognitive work by integrating “sensory, affective and motivational levels of representation in ways that can
help account for psychophysiological effects of symbolic interventions.”27
Metaphors used to represent an affliction shape how it experienced, how
it is viewed by others and how it is diagnosed and managed. They are central to healing, illustrating a mind–body connection often ignored in biomedicine. All medical systems use metaphors. Traditional Chinese,
Ayurvedic Indian, and Unani28 medical systems conceptualize health as a
state of balanced energies or substances resulting from a harmony between
the body, mind, nature, social, and spiritual realms. Disease indicates an
imbalance of energies or substances resulting from disharmony among
these realms. The metaphors of imbalance/disharmony inform the interventions aimed at restoring health. The body here is not assumed to be the
same everywhere, and any commonalities between patients’ experiences of
a malady are attributed to similarities in body-type or shared constitution
and environment.29
24
Technologies focused on female biology and pathologies are among the rapidly evolving
ones and include reproductive technologies (contraception and in vitro fertilization),
childbirth technologies (fetal monitors, hormones to induce birth), screening and hormone
therapy (Gaines and Davis-Floyd (2004)). This is because the standard universal machinelike human body created by biological reductionism in medicine is male and a female body
is found dysfunctional in as much as it deviate from this male “norm.” Feminists have long
criticized biomedicine for its “patronizing pathologization of the female” (Gaines and
Davis-Floyd (2004), 101).
25
Lock and Nguyen (2010), op. cit.
26
Deborah Lupton (2003). Medicine as Culture. London: Sage: 59.
27
Laurence J. Kirmayer (2004), op.cit., 37.
28
Greek based Middle Eastern, medicine that spread to South Asia with the spread of Islam.
29
Lock and Nguyen (2010), op. cit., 60.
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The “Bio” in Biomedicine 49
In contrast, biomedicine draws on multiple coexisting metaphors,
each emerging at a historical junction in the evolution of biomedicine.
A mechanistic metaphor is the dominant one and the earliest to develop
arising from industrialization’s focus on maintaining a healthy workforce.
With the development of microbiology and the germ theory of disease, a
military metaphor emerged framing the body as the “scene of total war
between ruthless invaders [microbes] and determined defenders.”30 The
physician is the commander-in-chief whose orders are to be executed by
nurses and therapists without questioning. Other metaphors include “the
gift of life” for organ donation and “persistent vegetative state” for comatose patients. Winslow sees these individual metaphors as complementary
parts of a system of metaphors in healthcare discourse that “work synergistically both to describe and preserve distinct meanings of health care.”31
In the dominant mechanistic metaphor, the body consists of progressively smaller parts (systems, organs, tissue, cells, genes, and molecules)
shielded by the skin from an outside world poised to invade it. These
parts, in biomedical thinking, can malfunction and could be examined
separately by various specialists, repaired with chemicals, surgery, or
radiation, and replaced with mechanical or biological parts. The patient
is the object of examination and the site of interventions in isolation from
the psycho-socio-spiritual and physical environment that are implicated
in affliction.32 Where other medical systems see imbalance in energies,
substances, or social relations, biomedicine attributes disease to invasion
of organisms or malfunction of parts. This is why it is more successful in
treating acute conditions than in treating chronic conditions like hypertension, type II diabetes, or heart disease where a patient’s behavior,
30
Emily Martin (1990). Toward an anthropology of immunology: The body as nation state.
Medical Anthropology Quarterly 4(4): 410–426.
31
G. R. Winslow (1996). Minding our language: Metaphors and biomedical ethics, in
E. E. Shelp (ed.), Secular Bioethics in Theological Perspective, Dordrecht, the Netherlands:
Kluwer Academic Publishers.
32
More humanistic models based on a “bio-psycho-social” approach and “holistic
medicine” that see patients more than a biological entity have gained public attention and
some traction in biomedicine, but the machine model remains dominant (Gaines and
Davis-Floyd (2004)). Unsatisfied patients seek “complementary” medicine alongside
biomedical intervention and are creating a market for these “alternative” interventions.
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modes of thinking, and social and physical environments are significant
contributing factors.33
Because biomedicine and its technologies are based on biological and
other natural sciences, it sees itself, and is seen as, representing empirical
“scientifically” proven facts and presumed to be an unbiased, culturallyneutral system of knowledge and practices. The claim of unquestioned
“objectivity” has been challenged by the early 20th century. Ludwig Fleck
argued that “phenomena that scientists work with are the products of
technologies, practices, and preconditioned ways of seeing and understanding” and the scientist does not stand external to the world under
study.34 Though biomedicine practitioners are taught to believe their craft
is science-based, typically evidence that supports established practices
and long held assumptions are adopted, while those challenging them are
resisted for decades before they are assimilated into medical education
and practice; this leads to an “evidence-practice gap.”35 There is new
emphasis on “evidence-based medicine” which is driven by a variety of
stakeholders.36 The “subjective” reporting of the patient is separate and
only supplementary to the “objective” findings of physical exams and
diagnostic technology upon which the classification of a condition is
based. The requirement of and reliance on evidence (usually quantitative,
measurable, and reproducible) demand the classification of disease and
dysfunction be standardized, categorized, and quantified. This implies
reliance on “norms” in which real people’s bodies often do not fit, and this
forces practitioners to choose between limited options into which to fit
their diagnosis and interventions.37
33
Lock and Nguyen (2010), op. cit.
Ibid., 18.
35
Gaines and Davis-Floyd (2004), op. cit., 97.
36
It is championed as much by practitioners as by healthcare insurers who, in order to
cover the cost, demand proven evidence of the efficacy for diagnostic and therapeutic
interventions.
37
In the US, there are limited diagnoses and only specific interventions for which a practitioner can get paid for a particular diagnosis. This not only frustrates practitioners who struggle to “fit” the findings and intervention into these limited options, but it also contributes to
the evidence-practice lag because practitioners are disincentivized to try new interventions
that they will not get paid for.
34
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3. The Globalization of Biomedicine
Biomedicine has spread around the world through a formal medical education system that produces physicians trained in its technologies, practices, ways of thinking and knowing, and its conceptualization of the
body. It has also spread among ordinary people who, even when they
cannot afford its interventions, cannot fully escape its reach as they
encounter its influence on traditional practitioners who are affected by its
discourses and appropriate its interventions.38 Biomedicine, however, is
not practiced exactly the same everywhere, and it undergoes a process of
appropriation or modification. Unlike the case in European countries,
medical practice in the United States is dominated by technology and
invasive procedures. In the global South, pharmaceutical drugs are
accessible without physicians and are taken along with traditional interventions. Biomedicine’s dominance has not eliminated other medical systems. Instead, they are used as “alternative” or “complementary” medicine.
In this “medical pluralism,” the systems borrow from each other.
Nevertheless, biomedicine privileges its status as modern and scientific
and discounts traditional medicines’ epistemology, demanding from practitioners adherence to biomedicine’s practice standards if they are to have
a place within the official healthcare delivery system.39,40 Pluralism creates a hybridity of sorts, but not on equal terms. Biomedicine attempts to
restrain competing systems, not only by questioning their efficacy, but also
by integrating their knowledge, medicines, and interventions by subjecting
them to its research and regulations.41,42
38
Lock and Nguyen (2010), op. cit.
Ibid.
40
For example, traditional midwives are disabused of “nonscientific” beliefs and “professionalized” by retraining, and pharmaceutical companies engage in bioprospecting by
harvesting then patenting indigenous medicines as new drugs on the global market which
natives cannot afford (Gaines and Davis-Floyd (2004)).
41
Lock and Nguyen (2010), op. cit.; Claire Wendland (2012). Animating bioemedicine’s
moral order: The crisis of practice in Malawian medical training. Current Anthropology
53(6): 755–788.
42
For example, when Tibetan healers attempt to tap into the global pharmaceutical market,
their interventions must pass the scrutiny of randomized trials and when they do, biomedical providers are able to prescribe these medicines and interventions. Yet, US based
Tibetan healers would be prosecuted for practicing medicine without license, if they used
39
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Biomedicine has eradicated some diseases, saved lives, and improved
people’s health. These achievements are not devalued by criticizing
biomedicine’s shortcomings or failures. Understanding the nature of
biomedicine’s social construction is not merely to critique its epistemology
and call for alternative ones; such understanding and recognition of the
various actors involved raises awareness and calls for vigilance about how
all this affects people and policies that have local and global impact.
Additionally, when a condition is medicalized, the focus shifts to medical
intervention rather than assessing the socio-economic and political factors
involved.43 This critique highlights biomedicine’s “deterministic logic,”44
reveals its hidden assumptions, and opens spaces where action for improvement is possible. How an issue is conceptualized is foundational to how,
and whether or not, it is addressed. Gaining this understanding and foregrounding these features of biomedicine enlightens the debates and deliberations of practitioners, scholars of religion, and policy makers. A similar
exploration of bioethics would enrich the deliberation.
4. Bioethics: The Birth of a Field
The 40-year-old field of bioethics originated from a history of exploitation
of research subjects and patients by the “medical–industrial complex.”45
Bioethics is an academic and applied field as well as a cultural phenomenon.46 Engelhardt contends that bioethics emerged from dramatic
cultural shifts (changes in medicine, moral pluralism, rising individualism, and distrust of tradition) in the United States that created a “moral
vacuum” and bioethics promised to provide moral guidance and manage
these interventions once they are appropriated by biomedicine (Seth 2009). See Suman
Seth (2009). Putting knowledge in its place: Science, colonialism, and the postcolonial.
Postcolonial Studies 12(4): 373–388.
43
Peter Conrad and Kristin K. Barker (2010). The social construction of illness: Key
insights and policy implications. Journal of Health and Social Behavior 51: S67–S79.
44
Ibid., S76.
45
Raymond De Vries (2011). The uses and abuses of moral theory in bioethics. Ethic
Theory Moral Practice 14: 419–430.
46
Gaines and Davis-Floyd (2004), op. cit., 103.
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The “Bio” in Biomedicine 53
diversity with a common language.47 To do so, the divergent voices and
substantial information needed for ethical decision-making were distilled
into a few principles that serve as a “commensurable unit” which, as
Evans put it, provides a common language and singular method for measuring differing features and simplifying decision-making.48 This concept
of commensuration captures the “lure of calculability and predictability”
that principlism promises, making it attractive to philosophers and
scientists alike.49
Though principlism offers potentially contradictory metric scales as its
four principles (autonomy, beneficence, nonmaleficence, and justice) are
weighed, the “system of commensuration” still applies because these principles offer a method to strip away the density of real life problems and fit
the moral dilemma into the metric.50 Beauchamp argues that the four principles he coformulated are simply “frameworks of general guidelines that
condensed morality to its central elements and gave people from diverse
fields an easily grasped set of moral standards.”51 Though its simplicity
and common language account for the spread of the principlism approach
to bioethics, the state accounts for both its birth through the Belmont
Report52 — the outcome of meetings at the behest of the state — and its
institutionalization through regulations and funding policies.53 Critics of
principlism see in its simplicity an oversimplification of complex moral
issues. David Callahan criticizes its diminished ability to engage and
benefit from the “insights of religion, of cultural observation and social
47
Tristram Engelhardt (2012). Bioethics after Four Decades: Looking to the Future,
Portuguese Association of Bioethics. Oporto, Portugal, 16 March 2012.
48
John H. Evans (2000). A sociological account of the growth of principlism. Hastings
Center Report 20(5): 31–38.
49
Ibid., 32.
50
Ibid.
51
Ibid., 32, 33.
52
This is a product of the 1979 National Commission for the Protection of Human Subjects
of Biomedical and Behavioral Research. The commission summarized its recommendations in the Belmont Report of Ethical Principles and Guidelines for the Protection of
Human Subjects of Research which continues to be the reference for all human related
research in all fields. Available online via http://www.hhs.gov/ohrp/humansubjects/
guidance/belmont.html (retrieved 20 July 2013).
53
Evans (2000), op. cit.
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analysis … and of concepts of human dignity and purpose that had a wider
scope than mere autonomy.”54
Bioethics has become synonymous with Georgetown University’s
principlism in a process that overshadowed the history of the term and the
theoretical diversity in the field. Bioethics as a concept was first coined
by van Rensselaer Potter at the University of Wisconsin-Madison. Potter,
a research oncologist concerned with the very survival of the human species, envisioned bioethics in broader terms with environmental and social
dimensions.55 Bioethics was to bridge the study of science, particularly
biology (bio), and humanities, which examines human values (ethics).56
For Potter, a defining feature of bioethics was “humility with responsibility” that will remind science it has no monopoly on truth nor can it alone
answer the complex questions.57,58 Potter knew that scientific knowledge
could be used to help or harm. He thought bioethics could offer the
“wisdom to manage dangerous knowledge” where values guide policy
deliberation on the effects of emerging scientific facts.59
Around the same time, Helleger and colleagues at Georgetown were
considering institutionalizing a new discipline that combines science and
social science along with religious and secular ethics — a bioethics project. The Georgetown approach to bioethics concerned Potter who saw
how it could confirm and maintain the biomedical field’s propensity to
focus on treatment and ignore prevention and social and environmental
causes of illness. Epistemologically, Potter’s and Georgetown’s approaches
differed in that Potter considered bioethics a “search for wisdom,” the
actionable knowledge that would equip us to arrive at “good judgment”
54
Ibid., 37.
Warren Thomas Reich (1994). The word “bioethics”: Its birth and the legacies of those
who shaped it. Kennedy Institute of Ethics Journal 4(4): 319–335.
56
Ibid.
57
As a scientist, Potter valued science’s great material progress and physical health contribution, but he questioned its being a source of wisdom because he saw it disconnected
from values. This inspired him to envision a multidisciplinary bioethics field that draws on
the contributions of science and the wisdom of human values (Reich (1995)). See Warren
Thomas Reich (1995). The word “bioethics”: The struggle over its earliest meanings.
Kennedy Institute of Ethics Journal 5(1): 19–34.
58
Henk ten Have (2012). Potter’s notion of bioethics. Kennedy Institute of Ethics Journal
22(1): 61.
59
Ibid., 64.
55
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The “Bio” in Biomedicine 55
regarding what makes for “physical, cultural, and philosophical progress
toward a valued survival.”60 The Georgetown approach focused on solving moral dilemmas presented by biomedical research and practice using
a standardized framework of common moral principles.
With public concerned about safeguarding individuals and communities from abuses in medicine and research, the simplicity of Georgetown’s
approach in dealing with pressing questions and Potter’s concern with
more entrenched environmental and social factors marginalized Potter’s
model, and principlism dominated.61 Two decades later, however, Potter
proposed a “Global Ethics.” Global in three senses: it focuses on issues
affecting the world, attends to issues of biomedical and environmental
concerns, and expands its ethical sources to include all “relevant values,
concepts and modes of reasoning and disciplines.”62,63 Potter’s global ethics is now reflected in the United Nations’ Universal Declaration on
Bioethics and Human Rights, which is concerned with health care, the
biosphere, future generations, and social justice.64
Though principlism is the most common theory, bioethicists draw on a
number of moral theories including casuistry and care ethics.65 This reliance
on moral theory and its ability to “solv[e] puzzles” rather than analyze social
structures, De Vries argues, is why bioethics theories focus on quick resolutions to ethical dilemmas and not on investigating the underlying causes.
Due to this tendency, some sociologists argue that American bioethics suffers from “cultural myopia” that makes it blind to its own socio-cultural
roots and resources66 and the “ethical dilemmas,” it adjudicates, further
60
Reich (1995), op. cit., 21.
Ibid., 19–34.
62
Ibid., 21.
63
Helleger, the cofounder of the Georgetown Kennedy Institute for ethics, was also advocating a global ethics (in all three senses) in his own work and was critical of the institute’s
more narrow approach though he continued to work there. Reich notes that Helleger’s
global approach drew on conscience and religion in answering the critical question of
“what do we think of the significance of the human?” He wanted bioethics that focused
more on “the crisis in values than with applying principles to biomedical dilemmas”
(Reich (1995), 28).
64
ten Have (2012), op. cit.
65
De Vries (2011), op. cit.
66
R Fox and J Swazey (1984). Medical morality is not bioethics — medical ethics in China
and the United States. Perspectives in Biology and Medicine Journal 27(3): 336–360.
61
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conceal that. What is needed, De Vries argues, is the crucial work of
“upstream bioethics” that will examine the social causes of these ethical
problems. That is precisely the imperative work for Muslim scholars of the
text and context. If that is not done, bioethicists (and religious scholars)
function as “the emergency department for ethical crisis” that triages the
urgent issues without examining and addressing the root causes of these
problems.67
As biomedicine globalizes, so does principlism. De Vries and Rott use
the metaphor of “missionary work” to describe this movement of bioethics from the West to the Global South. Here the gospel (“the good news”)
is not the Christian message, but “good clinical practice,” the Belmont
Report, and the Declaration of Helsinki.68,69 Benefiting from what
Christian missionaries had learned — that “indigenization” is more effective than “exportation” — De Vries notes, Western bioethics institutions
are bringing bioethicists from the developing world for training. These
“native” bioethicists acquire “the language and logic of Western bioethics”
then go back home to “spread the gospel” in linguistically and culturally
relevant ways.70 Both religious missionary and bioethics work have the
“noble intent” of sharing what proponents see as the benefit of advancement, but good intentions do not guarantee good results and could instead
cause harm. In these training programs, the power differential results in a
unidirectional flow of wisdom and values from the West to the rest.
Instead of exploring local wisdom and putting it in dialogue with Western
bioethics, the participants become competent in bioethics’ principles,
international regulations, and how to ensure proposed research adheres to
these standards.71 Training participants learn different ethical theories and
apply them to issues like reproductive technologies and genetics that are
of little relevance to their local situations. The absence of dialogue and
67
De Vries (2011), op. cit., 425.
The Declaration of Helsinki is a set of ethical guidelines developed by the World
Medical Association in 1964 and has since had several amendments. The declaration
outlines ethical principles to which those conducting medical research must adhere. For
details, http://www.who.int/bulletin/archives/79(4)373.pdf (retrieved 20 July 2013).
69
De Vries (2011), op. cit., 426.
70
Ibid.
71
Ibid., 419–430.
68
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The “Bio” in Biomedicine 57
mutual enrichment impoverishes bioethics both in the global South and in
the West. The dialogue could move us away from principlism’s contested
claims of universality based on a “common morality” which De Vries
argues is inappropriate and results in focusing too much on moral theory
and not enough on the necessary work of moral philosophy.72 De Vries’
proposed approach would draw on “distributive morality” instead of
“common morality.” Consequently, wholesale adoption or appropriation
of principlism would be replaced by a dialogue between the Western
ethical tradition and local moral traditions in a collaborative quest for and
proposal of ethical guidelines that are grounded in the local moral and
social world.73
Bioethics and its dominant theory of principlism are criticized by
diverse Western groups who challenge its purported universality and who
argue it erases their specificity. These critics contend that they have a
particular epistemic position that is shaped by their respective histories
and concerns as gender, sexuality, race, and religious-based groups. Each
group has contributions to make to bioethics based on its own epistemic
vantage point that enables particular insights. Garcia, for example, proposes that an African-American medical ethics perspective would be
“anti-majoritarian and anti-utilitarian, anti-situationalist, and distrustful
of an ‘ethics of trust’.”74 It is an approach “free from the bonds of scientism” and “open to insights from religious faith,” one in which the patient
is ultimately the decision maker but the role of family and community
are recognized without being “romanticiz[ed].”75 Garcia is not advocating a distinct African-American bioethics but argues for an ethics that is
“faithful, informed by, and seriously responsive to important forms of
experience characteristic of African-Americans, that is, informed and
responsive in its topics (foci), methods, and moral features, or content.”76
72
Ibid.
Ibid.
74
Jorge Garcia (2007). Revising African American perspectives on biomedical ethics:
Distinctiveness and other questions, in Edmund Pellegrino and Lawrence Prograis (eds.)
African American Bioethics: Culture, Race, and Identity, Washington, DC: Georgetown
University Press: 3.
75
Garcia (2007), op. cit., 2.
76
Garcia (2007), op. cit., 3.
73
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These experiences have been shaped by centuries of oppression, disenfranchisement, and discrimination embodied in lasting health problems
(such as diabetes, hypertension, and obesity) that disproportionately
affect African-Americans.77
Bioethicists speaking from a religious epistemic stance also argue for
the value and specificity of their contribution. Engelhardt, a physician
bioethicist, contends that bioethics is based on “secular fundamentalism”
that came to fill the moral vacuum left by the Enlightenment project and
accomplished what the Enlightenment could not, usurping religion’s
authority to define “good” and “right” and bestowing it on philosophers
and ethicists.78 Principlism’s claim to universality is that it derived the
four principles from a common morality. These principles are not exhaustive of the shared values and can be made specific by adding contextrelevant moral content.79 Engelhardt, who works both on secular and
Christian bioethics, challenges this universalist claim arguing that once
culture-specific contents are added, these moral principles diverge too far
to be common and bioethics remains challenged by moral plurality.80 He
distinguishes Christian bioethics for its “understand[ing] that the impersonal set of moral principles and goals in secular morality gives a distorted
account of the moral life” that is focused on relationship with God.81
Religiously-based values persist even in the West and continue to
inform medical ethical decision-making82 because of the existential and
77
Studies have shown that the prevalence of the low birth weight of African-American
children regardless of socio-economic status of the mothers is actually due to adaptive
changes in their genes due to the history of oppression and what Nancy Krieger called
“biologic expressions of race relations” (Lock and Nguyen (2010), 99).
78
Judah Goldberg and Alan Jotkowitz (2012). In defense of religious bioethics. The
American Journal of Bioethics 12(12): 32.
79
T. Beauchamp and J. Childress (2008). The Principles of Biomedical Ethics, 6th edn.
New York: Oxford University Press.
80
Tristram H. Engelhardt (2009). Moral pluralism, the crisis of secular bioethics, and the
divisive character of christian bioethics: Taking the culture wars seriously. Christian
Bioethics 15(3): 234–253.
81
Ibid., 234.
82
Social scientists and psychologists have found that, when grappling with these weighty
issues, people rely on moral intuition and religious values and not on the calculations of
rational secular ethics because questions of meaning are not always answerable by mere
deductive reasoning (Goldberg and Jotkowitz (2012), 32).
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The “Bio” in Biomedicine 59
metaphysical nature of the issues with which bioethics grapples. These
issues are not merely about resolving conflicts about distribution of social
goods.83 Advocates of Christian or Jewish bioethics are not arguing for
discarding secular bioethics, but like feminists and racial minorities, they
are arguing for “epistemological pluralism, in which deductive reasoning
is but one of many roads to ethical and moral knowledge. Direct intuition,
collective deliberation, and even received tradition — whether rooted in
theology or in non-religious culture — are all alternate, and complementary, pathways.”84 This, they posit, recalls bioethics’ roots; after all, its
founding fathers (Joseph Fletcher, Paul Ramsey, Immanuel Jakobovits,
and Richard McCormick) were writing from their respective religious
epistemic stances. Furthermore, if bioethics can accommodate its disparate ethical theoretical perspectives, why should religious ones not be part
of the sources of bioethics?85,86
5. Biomedicine and the Urgent Existential Questions
With mechanical device implantation, organ transplantation, genetic
manipulation, and potent pharmaceuticals, medical technology has
blurred the boundaries between self and other, life and death, and nationstates have shattered barriers considered natural or cultural and have
raised fundamental questions about what is normal or not, what is just and
moral and what is not, and what is human or not.87 Two issues, organ
transplantation and human enhancement, exemplify the great potential of
biotechnology and the existential ethical questions it raises.
5.1. “Brain Death” and What Makes us Human
The definition and meaning of death and what happens after death are
ontological and epistemological issues deeply embedded in a socio-cultural
83
Goldberg and Jotkowitz (2012), op. cit., 32.
Ibid.
85
Daniel Callahan (1990). Religion and the secularization of bioethics. Special supplement: “Theology, Religious Traditions and bioethics. Hastings Center Report 20(4): 2–4.
86
Goldberg and Jotkowitz (2012), op. cit.
87
Lock and Nguyen (2010), op. cit.
84
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milieu. Biomedical advances have brought unforeseen social and legal
challenges. For example, biotechnology that sustains artificial breathing
and/or circulation raises the question of when and if it is ethical to withdraw
it, and at which point can death be declared and organs procured? Only a
fraction of people with failing organs undergo organ transplantation. The
gap between supply and demand necessitated a new and problematic definition of death as “Brain Death.” Countries differ on whether the higher
brain, brainstem, or whole brain death defines death. In the United States,
the definition is “the irreversible cessation of all functions of the entire
brain, including the brain stem” (National Conference of Commissioners
on Uniform State Laws 1981),88 and 30 years later the debates are
unabated.
Central to the arguments of those in support of “brain death” criteria
are two interconnected ideas. One is the understanding that a human being
is a person because of the capacity for conscious experience which is
,
irreversibly lost when the brain is catastrophically damaged.89,90–91
The other
is that the brain serves an integrative role without which a single being
ceases to be and becomes a collection of organs. Proponents of brain death
argue that the person is dead, but the mechanical assistance to the heart
and lungs gives a false impression of life. However, once the mechanical
devices are disconnected, the cardiopulmonary function will cease and
death will be apparent to all. The assumption is that the organs of such an
individual would go to waste if not procured in time and, in light of the
number of people on waiting lists, that would be unethical. Some even
argue for a preliminary diagnosis of “imminent brain death” for patients
88
National Conference of Commissioners on Uniform State Laws (1981). The Uniform
Determination of Death Act 1981. Available online via http://lchc.ucsd.edu/cogn_150/
Readings/death_act.pdf (retrieved 6 July 2013).
89
Dr. David L. Perry (2001). Ethics and Personhood: Some Issues in Contemporary
Neurological Science and Technology.” Avaliable online via http://www.scu.edu/ethics/
publications/submitted/Perry/personhood.html (retrieved 6 July 2013).
90
Robert Truog and Franklin G. Miller (2008). The dead donor rule and organ transplantation. The New England Journal of Medicine 359(7): 674–675.
91
Alan D. Shewmon (2001). The Brain and somatic integration: Insights into the standard
biological rationale for equating ‘brain death’ with death. Journal of Medicine and
Philosophy 26(5): 457–478.
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The “Bio” in Biomedicine 61
who have sustained “irreversible catastrophic brain damage of a known
origin” so they are recognized early as potential organ donors.92,93
Physicians and bioethicists critical of brain death argue that the definition is based on a misunderstanding of death as an event and not a process.94
The tests of the irreversibility of function, in fact, cannot guarantee this
irreversibility; therefore, the definition fails to meet its own requirement.
In other words, “‘brain death’ is not even ‘brain death’.”95,96 Shewmon, a
pediatric neurologist, challenges the assumption that the brain performs the
integrative function for the whole body, arguing that somatic integration is
not locatable in one “critical” part. Instead, it is a “holistic phenomenon
involving mutual interaction of all the parts”; therefore, “the body without
brain function is surely very sick and disabled, but not dead.”97
These findings have made for very lively debates in bioethics,
philosophy, and medical publications. Yet they have not had any practical,
legal, or clinical impact and have not reached the public, leading Truog to
conclude that “Brain death [is] too flawed to endure, [but] too ingrained
to abandon.”98 To resolve this impasse, he proposed a change in the “dead
92
Y. J. de Groot, Jan Bakker, Eelco F. M. Wijdicks and Erwin J. O. Kompanje (2011).
Imminent Brain death and brain death are not the same: Reply to serheijde and Rady.
Intensive Care Medicine 37(1): 174.
93
De Groot et al. argue that this is not an early declaration of death, but “a tool for early
recognition of a potential organ donor” (2010, 174).
94
See Amir Halevy (2001). Beyond brain death? Journal of Medicine and Philosophy
26(5): 493–501; Mohamed Rady and Joseph L. Verheijde (2009). Islam and end-of-life
organ donation. Asking the Right Questions. Saudi Medical Journal 30(7): 882–886; and
Alan D. Shewmon (2009). Brain death: Can it be resuscitated? Hastings Center Report.
39(2): 18–24.
95
Critics argue this irreversibility is contradicted by the fact that the procured heart of an
individual considered “brain dead” because of suffering an irreversible cardiac arrest has
“successfully functioned in the chest of another” (Truog and Miller (2008), 674). This
reversi-bility might even occur during the procurement surgery when the artificial circulation intended to preserve organs may resuscitate vital signs of this “brain dead” donor (Rady
and Verheijde (2012)). See Truog and Miller (2008), op. cit.; Mohamed Y. Rady and Joseph
L. Verheijde (2012). Brain-dead patients are not cadavers: The need to revise the definition
of death in Muslim communities. Healthcare Ethics Committee Forum 25: 25–45.
96
Halevy (2001), op. cit., 498.
97
Shewmon (2009), op. cit., 473.
98
R. D. Truog (2007). Brain death — too flawed to endure, too ingrained to abandon.
Journal of Law, Medicine and Ethics, 273. Also available online via http://www.ncbi.nlm.
nih.gov/pubmed/17518853 (retrieved 1 July 2013).
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donor rule” and the “informed consent,” which does not fully disclose the
controversy around brain death. There have been calls for a moratorium
on the practice of cardiocirculatory death diagnosis in the context of organ
procurement as well until full public disclosure and a society-wide debate
0,
have taken place.99,10–101
Shewmon even suggested a footnote in the consent
form warning individuals that they may not be dead when their organs are
procured.102,103
This controversy reveals deep-rooted biological reductionism and
underlying body–mind dualism assumptions that raise ontological and
epistemological questions. There are those who locate the soul in the brain
and brain death is the loss of the “vital and unifying principle (‘substantial
form’) of the body.” Others also locate the soul in the brain but see brain
death as the “loss-of-personhood,” the “thinking substance, in principle
dissociable from an animal body the vitality of which is essentially
mechanistic.”104 In both positions, the separation and opposition of the
body and brain persist. This is because modernity changed meanings of life
and death, making them into legal and medical matters rather than metaphysical ones. This secularization of life and death, argued some intellectuals, relegated the divine to the private sphere and replaced the “soul” with
a rational “self” — the person — that is lost with “brain death” leaving
behind collections of organs that could be used by someone else.105
What are we to make of this human being who is in a liminal state of
“dead” mind but living body? This is not only confusing for ordinary
people who see no visible signs of death (the body is warm, breathing,
urinating, and growing) but also to medical practitioners whose biomedical
99
A. Joffe, J. Carcillo, N. Anton, A. deCaen, Y. Han, M. Bell et al. (2011). Donation after
cardiocirculatory death: A call for a moratorium pending full public disclosure and fully
informed consent. Philosophy, Ethics, and Humanities in Medicine 6(17): 6–17.
100
Truog and Miller (2008), op. cit.
101
Rady and Verheijde (2012), op. cit., 25–45.
102
Shewmon (2009), op. cit.
103
The footnote would say, “Warning: It remains controversial whether you will actually
be dead at the time of removal of your organs. This depends on the conceptual validity of
‘position two’ in the analysis of the determination of death conducted by the President’s
Council on Bioethics. You should study it carefully and decide for yourself before signing
an organ donor card” (Shewmon (2009), 18).
104
Shewmon (2001), op. cit., 475.
105
Lock and Nguyen (2010), op. cit.
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The “Bio” in Biomedicine 63
training tells them the person is dead but whose intuition tells them
otherwise.106 The general public is unaware of these doubts and debates.
The “gift of life” language of organ donation conceals “the significant
scientific and commercial interests that are at play,” and the language of
rights that dominates bioethics obscures the politics of commerce and corruption and the glaring inequalities that make poor people’s bodies serve
as spare parts for the well-to-do through medical tourism.107
5.2. Biological “Enhancement” and Transgenetics
Genetic manipulations of plants and animals had promised disease and
decay resistant nutritious food that would solve world hunger. Instead, it
has only enriched agribusiness, and we are confronted with unknown risks
to humans and non-humans alike. New trans-species genetic manipulations that turn animals and plants into factories for commercial products
and pharmaceuticals are emerging.108 Millions of animal neural cells have
been implanted in the brains of patients in clinical trials to address neural
dysfunctions.109 Studies of genetically modified pigs that could produce
organs for humans are seen as very promising in addressing the organ
donation shortage.110 These “advances” are great scientific feats that raise
critical ethical questions, most importantly about the essence of humans,
plants, and animals.
106
One experienced intensive care physician said that he lies awake wondering if the individual he declared brain dead “was that person really dead? It is irreversible — I know
that, and the clinical tests are infallible. My rational mind is sure, but some nagging,
irrational doubt seeps in.” (Lock and Nguyen (2010), 240).
107
Lock and Nguyen (2010), op. cit., 222.
108
The insertion of human gene into goats or chickens to produce antithrombin (blocks
blood clot formation) in their milk or eggs and adding a spider gene into goat to produce
silk-making proteins are examples of transgenic experiments that are hailed as great
scientific advances. R. R. Moura, L. M. Melo, and V. J. D. F. Freitas, (2011). Production
of recombinant proteins in milk of transgenic and non-transgenic goats. Brazilian Archives
of Biology and Technology 54(5): 927–938. A. Lazaris, S. Arcidiacono, Y. Huang, J. F.
Zhou, F. Duguay, N. Chretien, and C. N. Karatzas, (2002). Spider silk fibers spun from
soluble recombinant silk produced in mammalian cells. Science 295(5554): 472–476.
109
PBS, Frontline (2001). Organ Farm: Four Patients and Their Clinical Trials. Available
online via http://www.pbs.org/wgbh/pages/frontline/shows/organfarm/ (retrieved 1 July 2013).
110
Ibid.
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The possibility of selecting the sex of a child and removing “defective”
or “disease causing” genes seemed fictional a few years ago. However, the
first is now a reality, the latter is in the works, and both raise ethical
questions. Further, physical enhancement through cosmetic surgery,
growth hormones, performance enhancing drugs, and cognitive (appetite,
mood, concentration, and memory) enhancement through pharmaceuticals
are now routine though only accessible to those with material means. These
“enchantments” are but the first steps towards making “better people” and
what some have called trans-humanism or even post-humanism, where
surgery, genetic engineering, and ever smaller technologies inserted into
the body ostensibly defy aging and disease and make much “improved”
(stronger, smarter, faster, and better communicator) humans.111,112
The assumption driving biomedical technology and practice is that
genetic determinism fully accounts for health, illness, and who we
become. But research in genetics itself (epigenetics) is challenging that
paradigm and demonstrating the multiple possibilities for non-DNA based
mechanisms at play. But epigenetics too will not be able to answer fully
what is human nature or what makes humans who they are.113 Religious
fundamentalism justifiably invokes great fears, but there is also what
Elshtain called a “scientific fundamentalism” that reduces who a person is
or becomes to their DNA and sees the body as the site of a project of perpetual enhancement.114 But to what ends, and are there limits?115
111
Paul Miller and James Wilsdon (eds.) (2006). Better Humans? The Politics of Human
Enhancement and Life Extension. Demos. Available online via http://www.nanopodium.nl/
CieMDN/content/Demos_Better_humans.pdf (retrieved 1 July 2013).
112
Michael Hauskeller (2013). Cognitive Enhancement — To What End? Cognitive
Enhancement Trends in Augmentation of Human Performance 1: 113–123.
113
Lock and Nguyen (2010), op. cit.
114
Jean Bethke Elshtain (2008). Why science cannot stand alone. Theoretical Medicine
and Bioethics 29: 161–169.
115
With all the potential (negative or positive) of bioengineering technology, Watson
codiscoverer of DNA and Nobel prize winner, predicted a conflict between those who hail
these advances and those who question them on religious or ethical grounds and wondered
why would we not make better humans if we can (Lock and Nguyen (2010)). He argued
that if early genetic intervention spares individuals and families the “cruel fates” of the
“genetic dice” then to do nothing would be indecent because “if we don’t play God, who
will?” (Watson (1995), 197). See Lock and Nguyen 2010, op. cit.; James Watson (1995).
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The “Bio” in Biomedicine 65
Ethical issues abound. Beyond the health hazards inherent in crossing
species boundaries, do other species have rights to exist without being
tampered with to “benefit” humans? How do these other beings, now
embodied in the self, affect one’s sense of self?116 If you insert parts of
other beings (human or otherwise), does that affect “human nature?”
Science cannot answer these questions. They are more suited to being
tackled by philosophy and religions, but only if they are informed and
critically engaged.
6. Muslim Contributions
Muslim scholars of the text and medical practitioners enter the discussion
on biomedicine and its technologies in the context of questions about
reproductive technologies, cloning, withdrawing care, and organ donation. The specifics of each issue are outlined and scholars of the text are
confronted with conflicting medical opinions reflecting debates on these
issues within medicine. The two groups deliberate to arrive at consensus
on an “Islamic position.” The physicians not only offer medical facts but
they also engage in interpreting the religious texts from their perspectives
using current scientific facts. Physicians assertively defend their interpretations, at times pressuring scholars of the text to adopt certain positions117
Values from a Chicago upbringing. DNA: The double Helix perspective and Prospective
at 40 Years. Annals of the New York Academy of Science 758: 194–197.
116
Studies have shown the psychological issues that organ recipients of heart transplants
have apart from the persistent concerns about their health and survival there were also
concerns about acquiring habits, emotions, and thoughts of the donor. Often these reports
are dismissed as side-effect from medication or the work of active imagination and
“magical” beliefs as Inspector and David (2004) called it. Others argue the medication or
coincidence “are likely insufficient to explain the findings. The plausibility of cellular
memory, possibly systemic memory, is suggested” (Pearsall et al. (2000), 65). See
Y. Inspector, I. Kutz and D. David (2004). Another person’s heart: Magical and rational
thinking in the psychological adaptation to heart transplantation. Israel Journal of
Psychiatry and Related Sciences 41(3): 161–173; Paul Pearsall, Gary E. R. Schwartz and
Linda G. S. Russek (2000). Changes in heart transplant recipients that parallel the personalities of their donors. Integrative Medicine 2(2): 65.
117
Mohammed Ghaly (2012). The beginning of human life: Islamic bioethical perspectives. Zygon: Journal of Religion and Science 47(1): 175–213.
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or they contest the conclusions of collective fatāwā councils118 or challenge classic understandings about the nature of human beings and call
for an updated “completely naturalistic account of human personhood”
that is more consistent with biomedicine.119 Muslim physicians directly
accessing the religious texts and fatāwā councils’ conclusions are shaping
an emerging “Islamic bioethics” discourse.
While medical practitioners presumably speak objectively from a
“scientific” position, religious scholars, past and present, are frequently
faulted for lacking the scientific facts and interpreting texts from a particular epistemic position influenced by their gender, socio-cultural
milieu, and school of thought. However, Muslim medical practitioners,
their religious adherence notwithstanding, also speak from particular epistemic positions informed, among other things, by the ontological and
epistemological systems of biomedicine and science. They interpret religious discourse and debate issues informed by biomedicine’s metaphors
and conceptualization of the body and mind, illness, and nature and by the
triumphant narrative of science, technology, and progress.
Neither physicians nor textual scholars can claim a neutral and
“objective” stance; each knows and speaks from a particular epistemic
vantage point. If they only deliberate to answer the urgent ethical dilemmas, they become “staff” solving moral puzzles in what De Vries called
“the emergency department for ethical crisis.”120 What is needed, instead,
is a moral philosophy and the deliberation upstream about the underlying
causes of these dilemmas, the unspoken assumption of biomedicine, and
the existential questions about what makes us human beings: What is our
relationship with nature? What we can know? What ought we to do? What
we can hope for? These are not questions that can be “scientifically”
answered but ones that can be grappled with collaboratively utilizing
diverse ways of knowing including intuitive and revealed knowledge.
Though principlism dominates the bioethics theoretical landscape, it is
but a procedural ethics, a rubric for answering pressing clinical and research
ethical dilemmas. In answering these questions, however, bioethicists
118
Rady and Verheijde (2012), op. cit.
Omar Sultan Haque (2008). Brain death and its entanglements: A redefinition of
personhood for islamic ethics. Journal of Religious Ethics 36(1): 13.
120
De Vries (2011), op. cit.
119
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The “Bio” in Biomedicine 67
confront existential issues about the nature of human beings and the meaning of life and death. They try not only to understand what it is but also to
offer answers and guidance on what ought to be. These existential matters,
however, are the domain of religion and philosophy. To be relevant, experts
in religion and philosophy must not only be conversant about the current
biomedical technology and debates, but also about futuristic possibilities
and how those will impact individuals, societies, and nature. This way,
scholars not only respond to the actual problems but explore potential ones
that are on the verge of being actual and see the spaces between the actual
and the potential so as to chart a better future. Dismissing future possibilities as not-worth-the-time conjectures will have serious consequences.
An honest, social debate that seeks the insights of biomedical practitioners, scientists, social scientists, philosophers, religion scholars, and
ordinary people about biomedical research and practice, about the psychosocial-spiritual and politico-economic and environmental aspects of health
and well-being is imperative. Through it all, we have to consider the historical context that gave rise to biomedicine and its technologies and to
bioethics; we need to critically examine their current developments, interests, successes, and failures, and we have to assess the risk and opportunities they present for current and future generations. For Muslims to
criticize biomedicine and science as “Godless Western” systems and tools
of imperialist ambitions is to deny something of oneself; after all, modern
medicine and science stand on the shoulders of the Islamic civilization.
Nonetheless, to uncritically embrace these fields on the basis of these past
and present contributions or on the premise that Islam “has no problem
with reasoning and science” is to assume medicine and science today are
those of Ibn Sina and Ibn Rushd and to abdicate our responsibility. Muslim
contributions to ethics are lacking and urgently needed. A starting point is
to interrogate all that lies hidden in the space between “bio” and “ethics.”
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May 2, 2013
14:6
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Islamic Perspectives on the Principles of Biomedical Ethics
A Maqās·id-Based Approach
for New Independent Legal
Reasoning (Ijtihād)
Jasser Auda
Abstract: This chapter explores how the higher objectives of Sharia
(maqāsid al-sharī‘ah) could contribute to the application of the Sharia in
today’s reality, utilizing a few illustrative examples in the area of bioethics.
The soundness of Sharia’s application and related policies is subject to the
degree of universality and flexibility of the Islamic rulings with changing
circumstances, discussed from various viewpoints in this chapter. After a
survey of the system of values that the higher objectives of Sharia represent,
two reasoning (ijtihād) methods are explored: (i) differentiating between
scriptural texts that are means (wasā’il) to higher ends and those that are
ends (ahdāf) in their own right, and (ii) preferring a multidimensional
understanding for the conciliation of opposing juridical evidences, instead
of reductionist methods such as abrogation (naskh) and giving preference
to one opinion over another (tarjīh). A number of examples are provided
throughout the chapter in order to explain the impact of the proposed
methods on contemporary Islamic rulings.
69
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1. Introduction
Applications of the Sharia in any contemporary context or profession
require a methodology that represents the Sharia’s universality and flexibility with changing circumstances. Without the components of the Sharia
that are pertinent to accommodating various environments and cultures, or
in other words the dimensions of history and geography of the people, any
such application or policy would be counter-productive. This is because it
would jeopardize the very well known and absolute system of values and
principles of the Sharia itself, e.g. the principles of justice, wisdom,
mercy, and common good.
Shamsuddin bin Al-Qayyim (d. 748 AH/1347 CE) summarized these
principles with the following strong words:
Sharia is all about wisdom and achieving people’s welfare in this life
and the afterlife. It is all about justice, mercy, wisdom, and good. Thus,
any ruling that replaces justice with injustice, mercy with its opposite,
common good with mischief, or wisdom with nonsense, is a ruling that
does not belong to the Sharia, even if it is claimed to be so according to
some interpretation.1
The higher objectives of Sharia serve as a system of values that could
contribute to a desired and sound application of the Sharia. After a section
that introduces the system of values and the various theories of maqāsid,
this chapter suggests — in three consecutive sections — that it is necessary to determine the following:
(a) Whether a proposed ruling of the Sharia is an absolute and fixed end
in its own right, or whether it is in itself a means to an end and thus
subject to changing with changing circumstances. This method is
expressed in the following maxim: Differentiating between changing
means and absolute ends.
(b) Whether the Qur’anic verse or hadith under consideration should be
understood with another verse(s) or hadith(s), all in a unified context,
1
Shamsuddin, Ibn Al-Qayyim (1973). I’lām al-muwaqqi’īn (annotated by Taha Saad)
vol. 1. Beirut: Dar Al-Jeel: 333.
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or whether there is no “opposing evidence” that exists and requires such
consideration. This method is expressed in the following maxim:
Reconciling “opposing evidences” is better than ignoring some of them.
First, however, this next section will introduce maqāsid al-sharī‘ ah
as a system of values that has several theories, classifications, and viewpoints.
2. The Higher Objectives of Sharia as a System
of Values
Maqāsid al-sharī‘ah are the objectives/purposes/intents/ends/principles
behind the Islamic rulings,2 which found expression in the Islamic
philosophy/theory/fundamentals of law in various ways, such as public
interests (al-masālih al-’āmmah)3; “unrestricted interests” (al-masālih
al-mursalah)4; the avoidance of mischief (dar’ al-mafsadah)5; the wisdom
behind the scripts (al-hikmah)6; the appropriateness of the juridical
analogy (munāsabat al-qiyās)7; the basis behind juridical preference
(asl al-istihsān)8; the basis behind the presumption of continuity principle
(asl al-istishāb)9; and a large number of other tools for independent legal reasoning (ijtihād).
Recently, a large number of researchers from various backgrounds
attempted to explore the theory and application of the higher objectives of
2
Mohamed al-Tahir Ibn ‘Ashur (1997). Maqāsid al-sharī‘ah al-Islāmīyah (annotated by
Mohamed Al-Tahir Al-Mesawi). Kuala Lumpur: Al-Fajr: 183.
3
Abdul-Malik Al-Juwayni (1400 AH). Al-burhān fī uṣūl al-fiqh (annotated by Abdul-Azim
al-Deeb). Qatar: Wazarat al-Shu’un al-Diniyah: 183.
4
Abu Hamid Al-Ghazali (1413 AH). Al-mustaṣfá fī ‘ilm al-uṣūl (annotated by Mohammed
Abdul-Salam Abdul Shafi). vol. 1: Beirut: Dar al-Kutub al-’ilmiyah: 172.
5
Shihabuddin Al-Qarafi (1994). vol. 5: Al-dhakhīrah. Beirut: Dar al-Arab: 478.
6
Ali Al-Amidi (1404 AH). Al-ihkām fī uṣūl al-ahkām. vol. 5: Beirut: Dar al-Kitab
al-Arabi: 391.
7
Abdullah Ibn Qudama (1399 AH). Rawdat al-nāzir wa-jannat al-manāzir (annotated by
Abdul Aziz Abdul Rahman Alsaeed). vol. 3: Riyadh: Muhammed bin Saud University: 42.
8
Muhammad Al-Sarakhsi (n.d.). Uṣūl al-Sarakhsī. vol. 9: Beirut: Dar Alma’rifa: 205.
9
al-Izz Ibn Abdul-Salam (n.d.). Qawā’id al-ahkām fī maṣālih al-anām. vol. 1: Beirut: Dar
al-Nashr: 23.
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Sharia in various fields that belong not only to Islamic jurisprudence but
also to the social sciences and humanities.10
Purposes or higher objectives (maqāṣid) of Islamic law are themselves classified in various ways, according to a number of dimensions.
The following are some of these dimensions:
(i)
(ii)
(iii)
(iv)
Levels of necessity, which is the traditional classification.
Scope of the rulings aiming to achieve the purposes.
Scope of people included in the purposes.
Level of universality of the purposes.
Traditional classifications of the higher objectives divide them into
three “levels of necessity,” which are necessities (darūrīyāt), needs
(hājīyāt), and luxuries (tahsīnīyāt). Necessities are further classified into
what “preserves one’s religion, life, wealth, intellect, and offspring.”
Some jurists added “the preservation of honor” to the above five widely
popular necessities. These necessities were considered essential matters
for human life itself. There is also a general agreement that the preservation of these necessities is the “objective behind any revealed law,” not
just Islamic law.
Purposes at the level of needs are less essential for human life.
Examples are marriage, trade, and means of transportation. Islam encourages and regulates these needs. However, the lack of any of these needs is
not a matter of life and death, especially on an individual basis.
Purposes at the level of luxuries are “beautifying purposes,” such as
using perfume, wearing stylish clothing, and living in beautiful homes.
These are things that Islam encourages, but Islam also asserts that they
should take a lower priority in one’s life.
The levels in the hierarchy are overlapping and interrelated, as noted
by Imam Al-Shatibi (who will be introduced shortly). In addition, each
level should serve the level(s) below. Furthermore, the general lack of one
item from a certain level moves it to the level above. For example, the
decline of trade on a global level during the time of global economic crises
10
Mohammad Kamal Imam (2010). Al-dalīl al-irshādī ilá maqāṣid al-sharī‘ah al-Islāmīyah
(6 vols). London: al-Maqasid Research Centre.
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A Maqāsid-Based Approach 73
moves “trade” from a “need” into a “life necessity,” and so on. This is why
some jurists preferred to perceive necessities in terms of “overlapping
circles” rather than a strict hierarchy (see Figure 1 below).
Modern scholarship introduced new conceptions and classifications
of the higher objectives by giving consideration to new dimensions. First,
considering the scope of rulings they cover, contemporary classifications
divide maqāṣid into three levels11:
(i) General higher objectives: These higher objectives are observed
throughout the entire body of Islamic law, such as the necessities
and needs mentioned above and newly proposed higher objectives,
such as “justice” and “facilitation.”
(ii) Specific higher objectives: These higher objectives are observed
throughout a certain “chapter” of Islamic law, such as the welfare of
children in family law, deterring criminals in criminal law, and preventing monopoly in financial transactions law.
(iii) Partial higher objectives: These higher objectives are the “intents”
behind specific scripts or rulings, such as the intent of discovering
the truth in seeking a certain number of witnesses in certain court
cases, the intent of alleviating difficulty in allowing an ill and fasting
person to break his/her fasting, and the intent of feeding the poor in
banning Muslims from hoarding meat during Eid/festival days.
Figure 1. The classification of higher objectives based on their levels of necessity.
11
Nu’man Jughaym (2002). Ṭuruq al-kashf ‘an maqāṣid al-shar‘. Malaysia: Dar
al-Nafa’is: 26–35.
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Moreover, the notion of higher objectives has been expanded to
include a wider scope of people — the community, nation, or humanity in
general. Ibn ‘Ashur (also to be introduced shortly), for example, gave
higher objectives that are concerned with the “nation” (ummah) priority
over higher objectives that are concerned with individuals. Rashid Rida,
as a second example, included “reform” and “women’s rights” in his
theory of higher objectives. Yusuf Al-Qaradawi, a third example, included
“human dignity and rights” in his theory of the higher objectives. The
above expansions of the scope of higher objectives allow them to respond
to global issues and concerns and to evolve from “wisdoms behind the
rulings” to systems of values and practical plans for reform and renewal.
Contemporary scholarship has also introduced new universal higher
objectives that were directly induced from the scripts, rather than from the
body of fiqh (Islamic law) literature in the schools of Islamic law. This
approach, significantly, allowed the higher objectives to overcome the
historicity of Islamic law edicts and represent the scripts’ higher values
and principles. Detailed rulings would, in turn, stem from these universal
principles. The following are examples of these new universal higher
objectives:
(i) Rashid Rida (d. 1935 CE) surveyed the Qur’an to identify its higher
objectives, which included “reform of the pillars of faith, and
spreading awareness that Islam is the religion of pure natural disposition, reason, knowledge, wisdom, proof, freedom, independence,
social, political, economic reform, and women’s rights.”12
(ii) Al-Tahir Ibn ‘Ashur (d. 1907 CE) proposed that the universal higher
objective of Sharia is to maintain orderliness, equality, freedom,
facilitation, and the preservation of pure natural disposition (fitrah).13
It is to be noted that the purpose of “freedom” (hurrīyah), which was
proposed by Ibn ‘Ashur and several other contemporary scholars, is
different from the purpose of “freedom” (‘itq), which was mentioned
by jurists such as Al-Siwasi.14 ‘Itq is freedom from slavery, not
12
Mohammad Rashid Rida (n.d.). Al-wahī al-Muhammadī: thubūt al-nubūwah
bi-al-Qur’ān. Cairo: Mu’asasat Izziddin: 100.
13
Ibn ‘Ashur, 1997, op.cit., 183.
14
Kamaluddin Al-Siwasi (n.d.). Sharh fath al-qadīr. vol. 4: Beirut: Dar al-Fikr: 513.
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A Maqāsid-Based Approach 75
“freedom” in the contemporary sense. “Will” (mashī’ah), however,
is a well-known Islamic term that bears a number of similarities with
current conceptions of “freedom” and “free will.” For example,
“freedom of belief” is expressed in the Qur’an as the “will to believe
or disbelieve” (Qur’an 18:29). In terms of terminology, “freedom”
(hurrīyah) is a “newly-coined” purpose in the literature of Islamic
law. Ibn ‘Ashur, interestingly, accredited his usage of the term
hurrīyah to “literature of the French revolution, which were translated from French to Arabic in the 19th century CE,”15 even though
he elaborated on an Islamic perspective on freedom of thought,
belief, expression, and action in the mashī’ah sense.16
(iii) Muhammad Al-Ghazali (d. 1996 CE) called for “learning lessons
from the previous 14 centuries of Islamic history” and therefore
included “justice and freedom” as part of the higher objectives at
the level of necessities.17 Al-Ghazali’s prime contribution to the
knowledge of higher objectives was his critique on the literalist
tendencies that many of today’s scholars have.18 A careful look at
the contributions of Muhammad Al-Ghazali shows that there
were underlying higher objectives on which he based his opinions, such as equality and justice, and on which he based all his
famous new opinions in the area of women under Islamic law and
other areas.
(iv) Yusuf Al-Qaradawi (1926 CE–) also surveyed the Qur’an and
concluded the following universal higher objectives: preserving
true faith, maintaining human dignity and rights, calling people to
worship God, purifying the soul, restoring moral values, building
good families, treating women fairly, building a strong Islamic
nation, and calling for a cooperative world. However, Al-Qaradawi
explains that proposing a theory in universal higher objectives
15
Mohamed Al-Tahir Ibn ‘Ashur (2001). Uṣūl al-nizām al-ijtimā’ī fī al-Islām (annotated
by Mohamed Al-Tahir Mesawi). Amman: Dar al-Nafa’is: 256, 268.
16
Ibid., 270–281.
17
Jamal Atiyah (2001). Nahw taf ’īl maqāṣid al-sharī‘ah. Amman: al-Ma‘had al-‘Alami
lil-Fikr al-Islami: 49.
18
Mawil Izzi Dien (2004). Islamic Law: From Historical Foundations to Contemporary
Practice. Edinburgh: Edinburgh University Press: 131–132.
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should only happen after developing a level of experience with
detailed scripts.19
(v) Taha Al-Alwani (1354 AH/1935 CE–) also surveyed the Qur’an to
identify its “supreme and prevailing” higher objectives, which are,
according to him, “the oneness of God (tawhīd), purification of the
soul (tazkiyah), and developing civilization on earth (‘umrān).”20
All of the above-cited higher objectives were presented as they
appeared in the minds and perceptions of the above jurists. Therefore, the
structure of the higher objectives is best described as a “multidimensional” structure, in which levels of necessity, scope of rulings, scope of
people, and levels of universality are all valid dimensions that represent
valid viewpoints and classifications (see Figure 2 for an illustration of this
Figure 2. Various dimensions of the theories of maqāṣid.
19
20
Al-Qaradawi Yusuf (1999). Kayf nata’āmal ma’ al-Qur’ān al-’azīm? Cairo: Dar al-Shuruq.
Taha Jabir Al-Alwani (2001). Maqāṣid al-sharī‘ah. Beirut: IIIT and Dar al-Hadi: 25.
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A Maqāsid-Based Approach 77
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structure). As explained above, the next three sections explore different
ways of utilizing higher objectives towards a much needed contemporary
reasoning or independent legal reasoning (ijtihād) for the application of
the Sharia in new circumstances.
3. Differentiating between Changing Means
and Absolute Ends
Some scripts (Qur’anic verses or hadiths) are “scripts of means” (nuṣūṣ
wasā’il) and are not intended to be ends in their own right and hence are
not meant to be applied to the letter. A higher objective-based (maqāṣidī)
understanding of these scripts helps in identifying their true meaning and
intent.
For example, God states, “Hence, make ready against them whatever
force and horse mounts you are able to muster, so that you might deter
thereby the enemies of God, who are your enemies as well…” (Qur’an
8:60). “Horse mounts” are means and not “ends” in their own right that
should be literally sought. In fact, the whole concept of “getting ready
with force” is a means to the ends of justice and peace, rather than an end
in its own right. The late Sheikh Muhammad Al-Ghazali extended this
concept by differentiating between means (al-wasā’il) and ends (al-ahdāf ),
wherein he argued for the possibility of what he called “expiry” (intihā’)
of the former and not the latter. Sheikh Al-Ghazali mentioned the whole
system of the distribution of the booty of war as one example, despite the
fact that it is mentioned explicitly in the Qur’an.21 God states, “And know
that whatever booty you acquire [in war], one-fifth thereof belongs to
God and the Apostle, and the near of kin, and the orphans, and the needy,
and the wayfarer. This you must observe if you believe in God and in what
We bestowed from on high upon Our servant…” (Qur’an 8:41).
The above understanding validates today’s policies, in which army
personnel are compensated according to a scheme of salaries, ranks, and
benefits, which are categorically separate from any economic gains they
achieve via warfare.
21
Mohammad al-Ghazali (1996). Al-sunnah al-nabawīyah bayn ahl al-fiqh wa-ahl
al hadīth. Cairo: Dar Al-Shuruq: 161.
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Recently, Sheikhs Yusuf Al-Qaradawi and Faisal Mawlawi elaborated
on the importance of the “differentiation between means and ends” during
the deliberations of the European Council for Fatwa and Research. They
both applied the same concept to the visual sighting of Ramadan’s new
moon (hilāl) being mere means for knowing the start of the month rather
than being an end in its own right. Hence, they concluded that pure calculations shall be today’s means of defining the start of the month. Thus,
Ministries of Islamic Affairs, Ministries of Awqaf, and Houses of Fatwa
in various countries could correctly base their calendar decisions on official, astronomical reports and findings, instead of a costly contingency
plan every month, especially during the seasons of fasting and pilgrimage.
Sheikh Al-Qaradawi also applied the same concept to Muslim women’s
garment (jilbāb), amongst other things, which he viewed as mere means
for achieving the objective of modesty.22
A similar expression is Ayatollah Mahdi Shamsuddin’s recommendation
for today’s jurists to take a “dynamic” approach to the scripts, and “not to
look at every script as absolute and universal legislation, open their minds to
the possibility of ‘relative’ legislation for specific circumstances, and not to
judge narrations with missing contexts as absolute in the dimensions of time,
space, situations, and people.” He further clarifies that he is “inclined to this
understanding but would not base (any rulings) on it for the time being.”
Nevertheless, he stresses the need for this approach for rulings related to
women, financial matters, and jihād.23 Fathi Osman, as another example,
considered the “practical considerations” that rendered a woman’s testimony
to be less than a man’s, as mentioned in Al-Baqarah (Qur’an 2:282). Thus,
Osman “re-interpreted” the verse to be a function to these practical considerations, in a way similar to Al-Alwani’s approach mentioned above.24
Sheikh Hassan Al-Turabi holds the same view regarding many rulings
related, once again, to women and their daily-life practices and attires.25
22
Mohamed el-Awa (ed.) (2006). Maqāṣid al-sharī‘ah al-Islāmīyah: dirāsāt fī qadāyā
al-manhaj wa-majālāt al-tatbīq. London: Al-Maqasid Research Center: 85.
23
Medhi Shamsuddin (1999). Al-ijtihād wal-tajdīd fī al-fiqh al-Islāmī. Beirut:
al-Mu’assassah al-Dawliyah: 128–129.
24
Abdelwahab el-Affendi (ed.) (2001). Rethinking Islam and Modernity: Essays in Honour
of Fathi Osman. London: Islamic Foundation: 45.
25
Hassan al-Turabi (2000). Emancipation of Women: An Islamic Perspective. London:
Muslim Information Center: 29.
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A Maqāsid-Based Approach 79
To demonstrate the implication of the aforementioned higher objective-based approach to the area of bioethics, the differentiation between
means and ends in medicine and medical procedures is important. A number of scholars argue for the significance of “Islamic” or “Prophetic”
medicine, by which they mean the remedies and the specific tools that
were used during the time of the Prophet (PBUH26). The application of the
above idea to this context implies that medicine itself and medical procedures as well are changeable means and not fixed ends in their own right.
The saying of the Prophet (PBUH) that God did not reveal any ailment
without revealing its cure as well, as related in the canonical collection of
Bukhari, becomes the absolute end, and all procedures and medicines
become means to achieving that end.
4. A Multidimensional Understanding of “Opposing
Evidences”
In Islamic juridical theory, there is a differentiation between opposition or
disagreement (ta‘ārud or ikhtilāf ) and contradiction (tanāqud or ta‘ānud)
of scripts (Qur’anic verses or Prophetic narrations). Contradiction is
defined as “a clear and logical conclusion of truth and falsehood in the
same aspect” (taqāsum al-ṣidq wa-al-kadhib).27 On the other hand, conflict or disagreement between evidences is defined as an “apparent contradiction between evidences in the mind of the scholar” (ta‘ārud fī dhihn
al-mujtahid).28 This means that two seemingly disagreeing (muta‘ārid)
evidences are not necessarily in contradiction. It is the perception of the
jurist that they are in contradiction, which can occur as a result of some
missing information or dimension regarding the evidence’s timing, place,
circumstances, or other conditions.29
26
Editor’s note: PBUH is an abbreviation of the phrase “Peace and Blessings [of God] be
Upon Him” inserted after the name of the Prophet Muhammad (PBUH) in compliance
with God’s command to invoke peace and blessings upon him whenever his name is
mentioned.
27
Abu Hamid al-Ghazali (1961). Maqāṣid al-falāsifah. Cairo: Dar al-Ma’arif: 62.
28
Ahmad Ibn Taymiyah (n.d.). Kutub wa-rasā’il wa-fatāwā (edited by Abdur-Rahman
al-Najdi). Riyadh: Maktabat bin Taymiyah: 131.
29
Abdul-Aziz al-Bukhari (1997). Kashf al-asrār. vol. 3: Beirut: Dar al-Kutub al-’Ilmiyah: 77.
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On the other hand, true contradiction takes the form of a single episode
narrated in truly contradicting ways by the same or different narrators.30
This kind of discrepancy is obviously due to errors in narration related to
the memory and/or intentions of one or more of the narrators.31 The
“logical” conclusion in cases of contradiction is that one or more of the
narrations is inaccurate and should be rejected.
For example, Abu Hurayrah narrated, according to Bukhari: “Bad
omens are in women, animals, and houses.” However, also according to
Bukhari, Aisha narrated that the Prophet (PBUH) had said, “People during
the Days of Ignorance (jāhilīyah) used to say that bad omens are in
women, animals, and houses.” These two “authentic” narrations are at
odds with one another and one of them should be rejected. It is telling that
most commentators rejected Aisha’s narration, even though other “authentic” narrations support it.32 Ibn Al‘Arabi, for example, commented on
Aisha’s rejection of the above hadith as follows: “This [rejection] cannot
be taken seriously (qawl sāqit). Aisha is rejecting a clear and authentic
narration that is narrated through trusted narrators.”33
According to various traditional and contemporary studies on the
issue of disagreement (ta‘ārud), contradiction, in the above sense, is rare.
Most cases of ta‘ārud are disagreements between narrations because of an
apparently missing context, rather than being due to logically contradicting accounts of the same episode. There are three main mechanisms that
jurists have defined to deal with these types of disagreements in traditional schools of law34:
(i) Conciliation (al-jam‘ ): This method is based on a fundamental
rule stating that, “applying the script is better than disregarding it
(i‘māl al-naṣṣ awlá min ihmālih).” Therefore, a jurist facing two
30
Jasser Auda (2006). Fiqh al-maqāṣid: inātat al-ahkām al-shar‘īyah bi-maqāṣidihā.
Virginia: Al-Ma‘had al‘Alami lil-Fikr al-Islami: 65–68.
31
Ali Al-Subki (1983). Al-ibhāj fī sharh al-minhāj. Beirut: Dar al-Nashr: 218.
32
Auda (2006), op.cit., 106.
33
Abu Bakr Ibn al-Arabi (n.d.).‘Āridat al-Ahwadhī. vol. 10: Cairo: Dar al-Wahy
al-Mohammadi: 264.
34
Badran Badran (1974). Adillat al-tarjīh al-muta‘āridah wa-wujūh al-tarjīh baynahā.
Alexandria: Mu’assasat Shabab al-Jami‘ah, Chap. 4.
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A Maqāsid-Based Approach 81
disagreeing narrations should search for a missing condition or context and attempt to interpret both narrations based on it.
(ii) Abrogation (al-naskh): This method suggests that the latter evidence, chronologically speaking, should “abrogate” (juridically
annul) the former. This means that when verses disagree, the verse
that is (narrated to be) revealed last is considered to be an abrogating
evidence (nāsikh) and others to be abrogated (mansūkh). Similarly,
when Prophetic narrations disagree, the narration that has a later
date, if dates are known or could be concluded, should abrogate all
other narrations. Most scholars do not accept that a hadith abrogates
a verse of the Qur’an, even if the hadith were to be chronologically
subsequent.
(iii) The concept of abrogation, in any of the above senses, does not have
supporting evidence from the words attributed to the Prophet
(PBUH) in traditional collections of hadith. Etymologically, abrogation (naskh) is derived from the root na sa kha. I carried out a survey
on this root and all its possible derivations in a large number of
today’s popular collections of hadith, including, Al-Bukhari,
Muslim, Al-Tirmidhi, Al-Nasa’i, Abu Dawud, Ibn Majah, Ahmad,
Malik, Al-Darami, Al-Mustadrak, Ibn Hibban, Ibn Khuzaymah,
Al-Bayhaqi, Al-Darqutni, Ibn Abi Shaybah, and Abd Al-Razzaq.
I found no valid hadith attributed to the Prophet that contains any of
these derivations of the root na sa kha. I found about 40 instances of
“abrogations” mentioned in the above collections, which were all
based on one of the narrators’ opinions or commentaries, rather than
any of the texts of the hadith. Thus, I conclude that the concept of
abrogation always appears within the commentaries given by companions or other narrators, commenting on what appears to be in
disagreement with their own understanding of the related issues.
According to traditional exegeses, the principle of abrogation does
have evidence from the Qur’an, although the interpretations of the
related verses are subject to a difference of opinion.35
(iii) Giving preference (al-tarjīh): This method suggests giving preference
to the narration that is “most authentic” and dropping or eliminating
35
Muhammad Nada (1996). Al-naskh fī al-Qur’ān. Cairo: al-Dar al-Arabiyah lel-Kutub: 25.
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other narrations. The “preferred” narration is called al-riwāyah
al-rājihah, which literally means the narration that is “heavier in the
scale.” According to scholars of hadith, a weightier (rājihah) narration must have, as compared to the other narrations, one or more of
the following characteristics: a larger number of other supporting
narrations, a shorter chain of narrators, more knowledgeable narrators, narrators more capable of memorization, more trustworthy
narrators, first-hand account versus indirect accounts, shorter time
between the narration and the narrated incident, narrators able to
remember and mention the date of the incident more than others,
less ambiguity, and less rhetoric, in addition to a number of other
factors.
The Hanafi jurists apply abrogation before any other method, followed
by the method of tarjīh.36 All other schools of law give priority, theoretically, to the method of conciliation (al-jam‘ ). Although most schools of
law agree that applying all scripts is better than disregarding any of them,
most scholars do not seem to give priority, on a practical level, to the
method of conciliation. The methods that are used in most cases of ta‘ārud
are abrogation and tarjīh.37 Therefore, a large number of evidences are
canceled, in one way or another, for no good reason other than that the
jurists are failing to understand how they can fit them in a unified perceptual framework. Thus, invalidating these evidences is more or less arbitrary. For example, narrations are invalidated (outweighed) if narrators did
not happen to “mention the date of the incident”; the wording related to
the Prophet (PBUH) happened to be more “metaphoric”; or a narrator
happened to be female — in which case the male’s “opposing” narration
takes precedence.38 Therefore, naskh and tarjīh reflect the general feature
of binary thinking in fundamental methodology. It is essential that the
method of conciliation makes use of the concept of multidimensionality
36
Ibn Amir al-Haj (1996). Al-taqrīr wa-al-tahbīr fī ‘ilm uṣūl al-fiqh. vol. 3: Beirut: Dar
al-fikr: 4.
37
Auda (2006), op.cit., 105–110.
38
Abdul Majeed Al-Sousarah (1997). Manhaj al-tawfīq wa-al-tarjīh bayn mukhtalaf
al-hadīth wa-atharuh fī al-fiqh al-Islāmī. Amman: Dar al-Nafa’is: 395.
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A Maqāsid-Based Approach 83
in overcoming this drawback and considers the dimension of maqāṣid in
the understanding of the scripts.
One practical consequence of canceling a large number of verses and
Prophetic narrations in the name of naskh and tarjīh is a great deal of
“inflexibility” in Islamic law, i.e. inability to address various situations
adequately. Reflection upon pairs of muta‘ārid or opposing narrations
show that their disagreement could be due to a difference in surrounding
circumstances, such as war and peace, poverty and wealth, urban and rural
life, summer and winter, sickness and health, or young and advanced age.
Therefore, the Qur’anic instructions or the Prophet’s actions and decisions, as narrated by his observers, are supposed to have differed accordingly. Lack of contextualization limits flexibility. For example, the verse
that states, ‘But when the forbidden months are past, then slay the pagans
wherever you find them, and seize them’ (Qur’an 9:5) has come to be
named the ‘Verse of the Sword’ (āyat al-sayf) and has been claimed to
have abrogated hundreds of verses and hadith. One significant hadith that
was claimed to have been abrogated is “The Scroll of Medina” (ṣahīfat
al-madīnah), in which the Prophet (PBUH) and the Jews of Medina wrote
a “covenant” that defined the relationship between Muslims and Jews
living in Medina. The scroll stated that “Muslims and Jews are one nation
(ummah), with Muslims having their own religion and Jews having their
own religion.”39 Classic commentators on the ṣahīfah (Scroll) render it
“abrogated,” based on the Verse of the Sword and other similar verses.40
Seeing all the above scripts and narrations in terms of the single dimension
of peace versus war might imply a contradiction. This misunderstanding
eliminates the profession, ministry, and art of foreign policy altogether!
What augmented the problem is that the number of abrogation
claimed by the students of the companions (tābi‘ūn) is higher than the
cases claimed by the companions themselves, a fact I concluded on
the basis of the survey mentioned earlier. After the first Islamic century,
one could furthermore notice that jurists from the developing schools of
thought began claiming many new cases of abrogation that were never
39
Burhan Zurayq (1996). Al-ṣahīfah: mīthāq al-Rasūl. Damascus: Dar al-Numair & Dar
Ma‘ad: 353.
40
Ibid., 216.
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claimed by the tābi‘ūn. Thus, abrogation became a method of invalidating
opinions or narrations endorsed by rival schools of law. Abu Al-Hassan
Al-Karkhi (d. 951 CE), for one example, writes, “The fundamental rule is:
Every Qur’anic verse that is different from the opinion of the jurists in our
school is either taken out of context or abrogated.”41 Therefore, it is not
unusual in the fiqhī literature to find a certain ruling to be abrogating
(nāsikh) according to one school and abrogated (mansūkh) according to
another. This arbitrary use of the method of abrogation has exacerbated
the problem of lack of multidimensional interpretations of the evidences.
Multidimensional thinking, introduced by the higher objective-based
approach, could offer a solution to the dilemmas of a large number of
“opposing” evidences. Two evidences might be “in opposition” in terms
of one particular attribute, such as war and peace, order and forbiddance,
standing and sitting, men and women, and so on. If we restrict our view
to one dimension, we will find no way to reconcile the evidences.42
However, if we expand the one-dimensional space into two dimensions,
the second of which is a higher objective to which both evidences contribute, then we will be able to “resolve” the opposition and understand/
interpret the evidences in a unified context based on the purpose/maqṣūd
of both evidences.
For example, there is a large number of opposing evidences related to
different ways of performing “acts of worship” (‘ibādāt), all attributed to
the Prophet (PBUH). These opposing narrations have frequently caused
heated debates and rifts within Muslim communities. However, understanding these narrations within a higher objective of easiness (taysīr)
entails that the Prophet (PBUH) did carry out these rituals in various
ways, suggesting flexibility in such matters.43 Examples of these acts of
worship are the different ways of standing and moving during prayers,
concluding prayers (tashahhud), performing the compensating prostration
(sujūd al-sahū), reciting “God is Great” (takbīr) during ‘īd prayers,
making up for breaking one’s fasting in Ramadan, performing detailed
acts of pilgrimage, and so on.
41
Al-Alwani (2001), op.cit., 89.
Refer, for example, to: Abdullah Ibn Qutayba (1978). Ta’wīl mukhtalaf al-hadīth. Cairo:
Dar Al-Fikr Al-Arabi.
43
Auda (2006), op.cit., ch. 3.
42
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A Maqāsid-Based Approach 85
To present another example, a number of narrations were classified
under cases of abrogation even though they were, according to some jurists,
cases of gradual application of rulings. The purpose behind the gradual
applications of rulings on a large scale is, “facilitating the change that
the law is bringing to society’s deep-rooted habits.”44 Thus, “opposing
narrations” regarding the prohibition of liquor and usury and the performance of prayers and fasting should be understood in terms of the
Prophetic “tradition” and “policy” of the gradual application of high
ideals in any given society that is originally far from these ideals.
To apply the above fundamental concept in the area of bioethics, a
prominent example is the question of the permissibility of organ transplantation. Despite the fact that the majority of contemporary scholars
allow it, a few scholars judged prohibition. In terms of the technicalities
of the fatwá, there was a perceived “contradiction” between the scriptural
6,47,
evidences as highlighted in the following considerations45,4–48
:
(i) There is a well-known maxim — based on a number of evidences —
that one cannot offer what one does not own. On the other hand, an
analogy was made between offering an organ and offering money.
(ii) The perceived contradiction between the verse, “[Satan said]…I will
order them to change God’s creation” (Qur’an 4:119) and related
narrations, and the other verses and narrations that order reform and
doing good.
(iii) The perceived contradiction between the narrations that prohibit any
form of mutilation of corpses (such as “breaking the bone of the
dead is like breaking the bone of the living,” narrated by Ahmad,
Dawud, and Ibn Majah), versus the other consideration of common
good (maṣlahah).
44
Mohammad al-Ghazali (2002). Nazarāt fī al-Qur’ān. Cairo: Nahdat Misr: 194.
Abdullah al-Ghummari (1997). Ta‘rīf ahl al-Islām bi-ann naql al-‘udw harām. Palestine:
Mu’assasat Al-Albayt.
46
Mustafa al-Dhahabi (1993). Naql al-a‘dā‘bayna al-tibb wa-al-dīn. Cairo: Darul-Hadith.
47
Yusuf al-Qaradawi (w.d.). Mūjibāt taghayyur al-fatwá. Doha: International Union of
Muslim Scholars.
48
Yusuf al-Qaradawi (2009). Zirā‘at al-a‘dā’ fī al-sharī‘ah al-Islamīyah. Available online
via www.qaradawi.net (retrieved 1 June 2014).
45
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(iv) The perceived contradiction between the narrations that consider
organs separated from the living to be “dead” (maytah, narrated by
Ahmad, Tirmidhi, and others) — and thus prohibited to use because
of their impurity (najāsah) — versus the other narrations that stated
that “a believer could never be impure” (Bukhari and Muslim).
The sound methodology — based on this research — would give
prominence to the consideration of higher objectives in all of the above
evidences and similar ones, instead of the debates of abrogation and giving
preference to just one consideration over all others. Thus, the following
fatwá issued by the International Islamic Fiqh Academy (Al-Majma‘
Al-Fiqhī Al-Islāmī) in Jeddah represents — in my view — a sound methodology based on all of the above:
It is permitted to transplant or graft an organ from one part of a person’s
body to another, so long as one is careful to ascertain that the benefits of
this operation outweigh any harm that may result from it, and on the
condition that this is done to replace something that has been lost, or to
restore its appearance or regular function, or to correct some fault or
disfigurement which is causing physical or psychological distress.
It is permitted to transplant an organ from one person’s body to another,
if it is an organ that can regenerate itself, like skin or blood, on the condition that the donor is mature and understands what he is doing, and
that all other pertinent shar‘ī [Sharia-compliant] conditions are met.
It is permitted to use part of an organ that has been removed because of
illness to benefit another person, such as using the cornea of an eye
removed because of illness.
It is harām [impermissible] to take an organ on which life depends, such
as taking a heart from a living person to transplant into another person.
It is harām [impermissible] to take an organ from a living person when
doing so could impair an essential vital function, even though his life
itself may not be under threat, such as removing the corneas of both
eyes. However, removing organs which will lead to only partial impairment is a matter which is still under scholarly discussion.
It is permitted to transplant an organ from a dead person to a living person
whose life depends on receiving that organ, or whose vital functions are
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otherwise impaired, on the condition that permission is given either by
the person before his death or by his heirs, or by the leader of the Muslims
in cases where the dead person’s identity is unknown or he has no heirs.
Care should be taken to ensure that there is proper agreement to the
transplant of organs in the cases described above, on the condition that
no buying or selling of organs is involved. It is not permitted to trade in
human organs under any circumstances. But the question of whether the
beneficiary may spend money to obtain an organ he needs, or to show
his appreciation, is a matter which is still under scholarly debate.
Anything other than the scenarios described above is still subject to
scholarly debate, and requires further detailed research in the light of
medical research and shar‘ī rulings.
6. Conclusion
Before calling for the “application of the Sharia” in Muslim societies or
juridical systems, policy and methods have to be based on new ijtihād in
understanding and applying the evidences of the verses of the Qur’an or
the hadith of the Prophet (PBUH). In order for this ijtihād to meet the
needs of Muslims with changing circumstances, this chapter suggested
that it should be based on differentiating between changing means and
absolute ends. A higher objective-based understanding of these scripts
helps in identifying their purposes. Also, a multidimensional understanding of “opposing evidences,” which is based on a maqāṣidī approach,
offers a solution for the dilemma of the large number of “opposing” evidences in our juridical heritage. A higher objective-based approach is able
to “resolve” the opposition and understand/interpret the evidences in a
unified context based on the purpose/maqṣūd of both evidences.
Failing to include the above criteria in that proposed ijtihād would
create applications (or rather, misapplications) of the Sharia that are reductionist rather than holistic, literal rather than moral, and one-dimensional
rather than multidimensional. Thus, the proposed higher objective-based
approach lifts the juridical decisions and policies to a higher philosophical
grade and hence leads to a methodology that is holistic, ethical, and multidimensional. This methodology achieves a much needed flexibility of the
Islamic rulings with the change of time and circumstances, a flexibility
that is essential for the universality of Islam and its way of life.
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Principles of Biomedical Ethics
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The Principles of Biomedical
Ethics as Universal Principles
Tom L. Beauchamp
Abstract: The principal subject of this chapter is the role that principles play
in the so-called four-principles approach or principlism.1 The historical and
textual background of the positions I will defend are found in Principles of
Biomedical Ethics, which I coauthored with James F. Childress and in my
recent book Standing on Principles. In the first section, I investigate the
nature and sources of principles in recent biomedical ethics and provide an
analysis of the four-principles framework. The second section is devoted to
the central role played in the four-principles account by the theory of common
morality, which is comprised not only of principles (and rules), but also of
virtues, ideals, and rights. The third section shows how universal principles
1
This term was coined by K. Danner Clouser and Bernard Gert (1990). A critique of principlism. Journal of Medicine and Philosophy 15: 219–236. See later discussions and
formulations in Bernard Gert, C. M. Culver and K. Danner Clouser (2006). Bioethics:
A Systematic Approach. New York: Oxford University Press, chap. 4; Oliver Rauprich (2013).
Principlism, International Encyclopedia of Ethics. Wiley, online encyclopedia; John H.
Evans (2000). A sociological account of the growth of principlism, Hastings Center Report
30: 31–38; Michael Quante and Andreas Vieth (2002). Defending principlism well understood. Journal of Medicine and Philosophy 27: 621–649; Carson Strong (2000). Specified
Principlism. Journal of Medicine and Philosophy 25: 285–307; and Bernard Gert, C. M.
Culver and K. Danner Clouser, Common morality versus specified principlism: Reply to
Richardson. Journal of Medicine and Philosophy 25: 308–322.
91
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are fashioned into particular moralities and the circumstances under which
moral pluralism is consistent with universal morality. The fourth section
shows how general principles are made practical for particular moralities by
being made more specific, as suitable for particular circumstances. Finally,
in the fifth section, I show the relevance of principles for discussions of
human rights, multiculturalism, and cultural imperialism.
1. A Framework of Four Clusters of Principles
1.1. The Origins of Principles in Recent Biomedical Ethics
Principles that can be understood with relative ease by the members of
various disciplines figured prominently in the early developments in the
history of biomedical ethics during the 1970s and early 1980s. Frameworks
of general principles were readily understood by people with many different forms of professional training and from all moral traditions. The
distilled morality of universal principles gave people in a pluralistic society a shared and serviceable group of norms for the analysis of moral
problems.
Two published works were the original sources of interest in principles of biomedical ethics. The first was the Belmont Report (and related
documents) of the National Commission for the Protection of Human
Subjects,2 and the second was Principles of Biomedical Ethics.3 The goal
of the former was a general statement of principles of research ethics,
whereas the goal of the latter was to develop a set of general principles
suitable for biomedical ethics more broadly so that the principles could be
specified for particular ethical problems in medicine, research, and public
health. One of our proposals was that medicine’s traditional preoccupation
2
National Commission for the Protection of Human Subjects of Biomedical and
Behavioral Research, The Belmont Report: Ethical Principles and Guidelines for the
Protection of Human Subjects of Research. Washington, DC: DHEW Publication. For history and commentary, see also James F. Childress, Eric M. Meslin, Harold T. Shapiro,
(eds.) (2005). Belmont Revisited: Ethical Principles for Research with Human Subjects.
Washington, DC.: Georgetown University Press.
3
Tom L. Beauchamp and James F. Childress (1979). Principles of Biomedical Ethics, 1st
edn. New York: Oxford University Press; the book is currently in the 7th edn., New York:
Oxford University Press, 2012.
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with a beneficence-based model of physician ethics be augmented by a
principle of respect for autonomy and by wider concerns for social justice.
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1.2. Principles as Abstract Norms of Obligation
In principlist theory, a basic principle is an abstract moral norm that is
part of a framework of prominent starting-points in the landscape of the
moral life. If some principles were dropped from the framework, the
demands of the moral life would not be what we know those demands to
be, just as a landscape would not be the same landscape if certain rocks,
trees, or plants were removed from it. In the absence of any one basic
principle there might still be a moral life, but it would be fundamentally
different from the one familiar to us. More specific rules for health care
ethics can be formulated by reference to these general principles, but neither rules nor practical judgments can be straightforwardly deduced from
the principles.
All principles can, in some contexts, be justifiably overridden by other
moral norms with which they come into contingent conflict. For example,
we might justifiably not tell the truth in order to prevent someone from
killing another person. Principles, duties, and rights are not absolute (or
unconditional) merely because they are universally valid. No principles,
duties, or rights are absolute. Often some balance between two or more
principles must be found that requires some part of each obligation to be
discharged, but in many cases one principle simply overrides the other.
This overriding may seem precariously flexible and subjective, as if moral
guidelines lack backbone and can be magically waived away as not real
obligations. In ethics, as in law, there is no escape from an exercise of
judgment in using principles in the resolution of moral conflicts. In some
limited contexts (for example, in religious ethics and in professional ethics) we may need to develop a highly structured moral system or set of
guidelines in which a certain class of rights or principles has a fixed priority over others, but no moral theory or professional code of ethics has
successfully presented a system of moral principles free of conflicts and
exceptions.
I will discuss this problem further below when addressing the problem of specification.
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1.3. A Framework of Principles
The principles in the framework that Childress and I have defended are
grouped under four general categories: (i) respect for autonomy (a principle requiring respect for the decision-making capacities of autonomous
persons), (ii) nonmaleficence (a principle requiring the avoidance of causing harm to others), (iii) beneficence (a group of principles requiring both
lessening of and prevention of harm as well as provision of benefits to
others), and (iv) justice (a group of principles requiring fair distribution of
benefits, risks, and costs across all affected parties).
The choice of these four general clusters of moral principles as the
framework for moral decision-making in bioethics derives in significant
part from professional roles and traditions. In this regard, our framework builds on centuries of tradition in medical ethics. Nonmaleficence
and beneficence have always played a fundamental role in the history
of medical ethics, whereas respect for autonomy and justice were
neglected and have risen to prominence only recently. All four types of
principles are needed to provide a comprehensive framework for biomedical ethics, but this framework is abstract and thin in content until it
has been further specified — that is, interpreted and adapted for particular circumstances — a task to which I return later.
In this section I will examine only the basic content of each of these
four clusters of principles.
(a) Respect for Autonomy
The starting point for an account of autonomy is self-rule free of controlling interferences by others and freedom from limitations within the
individual that prevent choice. The two basic conditions of autonomy
therefore are liberty (the absence of controlling influences) and agency
(self-initiated intentional action). Disagreement exists over how to analyze these two conditions and over whether additional conditions are
needed.4 Each of these notions is indeterminate until further analyzed in a
theory of autonomy.
4
See the different conceptual analyses of autonomy and theories of autonomy in Joel
Feinberg (1986). Harm to Self, vol. 3 in The Moral Limits of the Criminal Law. Chaps. 18–19.
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The Principles of Biomedical Ethics 95
To respect an autonomous agent is to recognize with due appreciation
person’s capacities and perspectives, including his or her right to hold
certain views, to make certain kinds of choices, and to take certain actions
based on personal values and beliefs. The principle of respect for autonomy contains both a negative obligation and a positive obligation.5 As a
negative obligation, autonomous actions should not be subjected to controlling constraints by others. As a positive obligation, this principle
requires respectful and appropriate informational exchanges and fitting
actions that foster autonomous decision-making. Respect for autonomy
obligates professionals in healthcare and research involving human subjects to disclose information, to probe for and ensure understanding
and voluntariness, and to foster adequate decision-making. True respect
requires more than mere non-interference. It includes, at least in some
contexts, building up or maintaining others’ capacities for autonomous
choice while helping to allay fears and other conditions that destroy or
disrupt their autonomous actions. Disrespect, on this account, involves
attitudes and actions that ignore, insult, demean, or are inattentive to others’ rights of autonomy.
Professional ethics is commonly concerned with such failures to
respect a person’s autonomy, ranging from manipulative under-disclosure
of pertinent information to non-recognition of a refusal of medical interventions. For example, in the debate over whether autonomous, informed
patients or their families have the right to refuse medical interventions, the
principle of respect for autonomy demands that an autonomous refusal of
interventions must be respected.6
This truly basic principle has been deeply misrepresented in much of
the bioethics literature as a principle of individualism, sometimes
New York: Oxford University Press, and Sarah Buss (2008). Personal Autonomy, Stanford
Encyclopedia of Philosophy. Available online via http://plato.stanford.edu/entries/
personal-autonomy/ (retrieved on 9 August 2012).
5
Editor’s note: These two types of obligation, i.e. the negative and positive ones, are very
close to the two parallel concepts in the discourse on the higher objectives of Sharia that
preserving each of these higher objectives also has two aspects, al-ifz ̣ al-wujūdī and
al-ifz ̣ al-‘adamī. The former can be translated as the positive obligation, and the latter
can be translated as the negative obligation.
6
Ruth R. Faden and Tom L. Beauchamp (1986). A History and Theory of Informed
Consent. New York: Oxford.
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curiously said to be an “American individualism.” But the principle of
respect for autonomy has nothing to do with individualism — the strange
idea that an individual has the right to do whatever the individual wishes
to do with his or her life and to take whatever actions he or she wishes.
Nothing is more antithetical to morality than individualism, and the fourprinciples approach wholly rejects it.
A related misunderstanding of both the four-principles approach and
of the principle of respect for autonomy is that it prioritizes the principle
of respect for autonomy over other principles and demands in the moral
life. Professor Ali Al-Qaradaghi says in his presentation that “the principlist approach prioritizes the principle of respect for autonomy over other
principles and demands in the moral life.” This statement is incorrect. We
do not prioritize this principle — or any principle. However, I hasten to
add that the Professor does have a fundamentally correct understanding of
our general view when he says that, in our view, “exercises of autonomy
can justifiably be restrained or overridden. In this way, it is clear that this
principle is not absolute.” Yes, that is exactly the right interpretation. As
Childress and I have pointed out, in edition after edition, the principle of
respect for autonomy has no priority whatsoever, nor does any other principle in the four-principles approach.
It has also been alleged that our book emphasizes a liberal political
philosophy of individual rights, while neglecting solidarity, social responsibility, social justice, health policy priorities, and the like. Given our very
substantial emphasis throughout the book on both beneficence and social
justice as basic principles, this interpretation seems to pay no serious
attention to what Childress and I have been writing for 40 years now.
Respect for autonomy in our work is not local to any region, not excessively individualistic, and not an overriding or ranked principle.
Many kinds of competing moral considerations can validly override
respect for autonomy under conditions of a contingent conflict of norms.
For example, if our choices endanger the public health, potentially harm
innocent others, or require a scarce and unfunded resource, exercises of
autonomy can justifiably be restrained or overridden. Childress and I also
defend a limited paternalism in physician care of the patient.
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(b) Nonmaleficence
The principle of nonmaleficence is the best example of a centuries-old
principle in medical ethics. This principle states that we are obligated to
abstain from causing harm to others. It has long been associated in
Hippocratic medical ethics with the injunction: “Above all [or first] do no
harm.” The reason for the esteem — almost reverence — for this traditional principle is perfectly understandable, in my view: Of all the basic
principles of biomedical ethics, there is none more basic and none more
important than the principle of nonmaleficence.
In a classic source of medical ethics, British physician Thomas
Percival maintained that a principle of nonmaleficence fixes the physician’s primary obligations and triumphs even over respect for the patient’s
autonomy in a circumstance of potential harm to patients:
To a patient … who makes inquiries which, if faithfully answered, might
prove fatal to him, it would be a gross and unfeeling wrong to reveal the
truth. His right to it is suspended, and even annihilated; because … it
would be deeply injurious to himself, to his family, and to the public.
And he has the strongest claim, from the trust reposed in his physician,
as well as from the common principles of humanity, to be guarded
against whatever would be detrimental to him.7
The principle of nonmaleficence supports a wide variety of more specific moral rules.8 Typical examples include:
(i) “Don’t kill.”
(ii) “Don’t cause pain or suffering to others.”
(iii) “Don’t incapacitate others.”
7
Thomas Percival (1803). Medical Ethics: Or a Code of Institutes and Precepts, Adapted
to the Professional Conduct of Physicians and Surgeons. Manchester: S. Russell:
165–166.
8
See Beauchamp and Childress (2012), 7th edn.: 154.
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Precisely how these rules are supported by the principle of nonmaleficence is not a question I will consider here, but it is addressed in the
Principles of Biomedical Ethics largely in terms of the theory of specification (as discussed below).
Numerous problems of nonmaleficence are found in health care ethics
today, some involving blatant abuses and others involving subtle and
unresolved questions. Blatant examples of failures to act nonmaleficently
are found in the use of physicians to classify political dissidents as mentally ill, thereafter treating them with harmful drugs and incarcerating
them with insane and violent persons.9 More subtle examples are found in
the use of medications for the treatment of aggressive and destructive
patients. These common treatment modalities are helpful to many patients,
but they can be harmful to others.
When I use the term “harm” in expositing nonmaleficence, I do not
mean to imply wrongful injuring or maleficence. I mean “harm” to refer
in a non-judgmental way to a thwarting, defeating, or setting back of the
interests of an individual, whether caused intentionally or unintentionally. The word “interest” here refers to that which is in an individual’s
interest — that is, what is to one’s welfare advantage in a given circumstance. A harmful invasion by one party of another’s interests is not
always wrong, maleficent, or unjustified.10 For example, there can be a
justified amputation of a patient’s leg, justified punishment of physicians
for incompetence or negligence, justified imprisonment, etc. Harming
therefore is not necessarily wronging.
(c) Beneficence
No moral demand placed on physicians is more important than beneficence in the care of patients. Beneficence is a foundational value —
sometimes treated as the foundational value11 — in healthcare ethics.
Many specific duties in medicine, nursing, public health, and research are
9
See, for example, Sidney Bloch and Peter Reddaway (1984). Soviet Psychiatric Abuse:
The Shadow over World Psychiatry. Boulder, Colo.: Westview Press, esp. chap. 1.
10
Beauchamp and Childress (2012), 7th edn., chap. 5.
11
Edmund Pellegrino and David Thomasma (1988). For the Patient’s Good: The
Restoration of Beneficence in Health Care. New York: Oxford University Press.
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The Principles of Biomedical Ethics 99
expressed in terms of a positive obligation to come to the assistance of
those in need of treatment or in danger of injury.
Principles of beneficence require that we prevent harms from occurring, remove harm-causing conditions that exist, and promote the good of
others. The physician who professes to “do no harm” is not usually interpreted as pledging never to cause harm, but rather to strive to create a
positive balance of goods over inflicted harms. Those engaged in medical
practice, research, and public health know that risks of harm presented by
interventions must often be weighed against possible benefits for patients,
subjects, and the public.
Rules of beneficence often demand more of us than the principle of
nonmaleficence because agents must act to help, not merely refrain from
harming, which is what is demanded by the principle of nonmaleficence.
Conflating nonmaleficence and beneficence into a single principle — as
some philosophers do — obscures some important distinctions. Obligations
not to harm others, such as those prohibiting disablement and killing, are
distinct from obligations to help others, for example, those prescribing the
provision of benefits and protection of interests. Professor Ali Al-Qaradaghi
says in his presentation, in objecting to the sharp distinction I make
between beneficence and nonmaleficence, that, “Actually, one can argue
that the principle of beneficence implies that of nonmaleficence and preventing harm.” In principlist theory, such an implication of one principle
by another does not occur. Nonmaleficence requires not acting — that is,
abstaining from acting so as not to cause harm. Beneficence requires
acting — in particular acting to benefit others. Here it is apparent that
beneficence cannot involve nonmaleficence because they are logically
and morally different principles.
Some writers in healthcare ethics suggest that certain duties not to
injure others are always more compelling than duties to benefit them.
They point out that we do not consider it justifiable to kill a dying
patient in order to use the patient’s organs to save two others, even
though benefits would be maximized, all things considered. The obligation to not injure a patient by abandonment has been said to be stronger
than the obligation to prevent injury to a patient who has been abandoned by another (under the assumption that both are moral duties).
Despite the intuitive attractiveness of these claims, there is no hierarchical
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ordering rule that ranks nonmaleficence higher than beneficence; obligations of beneficence do, under many circumstances, outweigh those
of nonmaleficence. A harm inflicted by not avoiding causing it may be
negligibly small, whereas the harm that beneficence requires we prevent
may be substantial. For example, saving a person’s life by a blood transfusion clearly justifies the inflicted harm of venipuncture on the blood
donor.
Perhaps the major theoretical problem about beneficence is whether
the principle generates general moral duties that are incumbent on
everyone — not because of a professional role, but because morality itself
makes a general demand of beneficence. Many analyses of beneficence in
ethical theory (most notably in utilitarianism12) seem to demand severe
sacrifice and extreme generosity in the moral life — for example, giving a
kidney for transplantation or donating bone marrow to a stranger. However,
such beneficent action generally follows from a moral ideal, not a principle of obligation. The line between what the principle of beneficence
requires and does not require is undoubtedly difficult to draw, and drawing
a precise line independent of the considerations of specific contexts is an
impossible goal.
(d) Justice
A person in any society has been treated justly if treated according to what
is fair, due, or owed. For example, if equal political rights are for all citizens, then justice is done when those rights are accorded. The narrower
concept of distributive justice refers to fair distribution in society of primary social goods, such as economic goods and fundamental political
rights, but burdens should also be within its scope. Paying for a national
health plan of insurance is a distributed burden; grants to do biomedical
research are distributed benefits.
A prime example of the need for principles of distributive justice is
the need to distribute healthcare and its costs fairly within societies. Some
governments, especially the United States, tend to pay for many useless
12
Peter Singer (1999). Living high and letting die. Philosophy and Phenomenological
Research 59: 183–187; Peter Singer (1993). Practical Ethics, 2nd edn. Cambridge: Cambridge
University Press; Shelly Kagan (1989). The Limits of Morality. Oxford: Clarendon Press.
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The Principles of Biomedical Ethics 101
procedures — a waste of resources that deprives others in society of
adequate healthcare. Various governments have concluded that their
resources are so limited that little money can be spent on either public
health or healthcare. A basic ethical problem in every society is how to
structure a principled system such that burdens and benefits are fairly and
efficiently distributed and a threshold condition of equitable levels of
health and access to healthcare is in place. These ethical objectives are
intertwined in the formation of health policy, both internationally and in
the policies of individual nations. Moral assessment of the justice of the
principles used in these systems is one of the major priorities in contemporary bioethics.
It is easy to get lost in the complications of theories of justice, and this
can easily cause a misunderstanding of what Childress and I are arguing in
the book. Dr. Al-Bar has a misunderstanding of our book when he says that
Beauchamp and Childress in “Principles of Biomedical Ethics” stressed
the fact that Afro Americans without medical insurance and found to
suffer from hypertension … should not be treated, as many researchers
found that such poor patients, will not be able to continue medication or
follow up.… In fact, without saying it, they agree to let them suffer and
die with their hypertension and its sequelae e.g. strokes, heart attacks,
heart failure, and kidney failure.… Instead of attacking this unjust system which excludes 50 million citizens from the right of being treated,
they make quasi scientific research that claims it is useless to treat such
patients.
There are several mistaken understandings here. First, we argue
repeatedly that African-Americans must be treated equally; in the passage
on hypertension we are criticizing theories that have a utilitarian rationale
that we do not accept. The theory under discussion in this passage is not
our theory; we are criticizing a theory presented by Professors Milton
Weinstein and William B. Stason.13 We call their theory a “problematic”
13
Milton Weinstein and William B. Stason (1977). Hypertension. Cambridge, MA:
Harvard University Press. Public health rounds at the Harvard School of Public Health:
Allocating of resources to manage hypertension. New England Journal of Medicine
296: 732–739; and (1977). Allocation resources: The case of hypertension. Hastings Center
Report 7 (October): 24–29.
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distribution scheme.14 Dr. Al-Bar says that we should be “attacking this
unjust system,” but this is exactly what we do — attack it. We critique all
such views at great length in our chapter on justice, where we spend some
50 pages in the book attacking precisely this unjust system. Dr. Al-Bar
says, “It’s amazing to find these two eminent philosophers of bioethics try
to find excuses for not treating the Afro Americans.” But we had just spent
numerous pages trying to criticize and restructure the system of healthcare
in the United States that gave rise to this problem. Our arguments consistently attack discrimination against African-Americans.
Professor Ali Al-Qaradaghi has a similar misunderstanding. He says,
“[T]hey [Beauchamp and Childress] did not include equal treatment of all
patients in the biomedical ethics. This is an important principle that
requires equality and fair treatment without discrimination based on
wealth, race, etc.” But the claim here is the exact opposite of what we say.
We insist on equal treatment of all patients and on the fundamental importance in the biomedical ethics of the principle that requires equality and
fair treatment. In fact, we claim even more since we insist on a principle
of fair opportunity.
In reading our account of justice, it is important not to look at passages in isolation from the larger theory. Our account of justice is fundamentally that of the moral necessity of creating a just system of healthcare
using a suitable model of egalitarian social justice, for both national and
international systems of distribution of public health services and healthcare goods.
There is no single principle of justice in the four-principles approach
because no single moral principle is capable of addressing all problems
of justice. Childress and I have largely defended a group of principles
arising from egalitarian theory — for example, the fair opportunity principle, which requires that social institutions affecting healthcare distribution should be arranged, as far as possible, to allow each person to
achieve a fair share of the normal range of opportunities present in that
society. The fair opportunity principle demands that individuals not
receive social benefits on the basis of undeserved advantageous properties
14
Beauchamp and Childress, Principles of Biomedical Ethics, 5th edn.: 347 as used by
Dr. Al-Bar.
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The Principles of Biomedical Ethics 103
and should not be denied social benefits on the basis of undeserved
disadvantageous properties, because they are not responsible for these
properties.15 I am also influenced by principles of justice that require
social support of essential core dimensions of well-being, such as health.
These principles require that a decent level of health care be distributed
either equally to all citizens or as needed for citizens to achieve a basic
level of well-being.16
Childress and I take account of the fact that philosophers have developed diverse theories of justice that provide sometimes conflicting principles of justice. We try to show that some merit is found in egalitarian,
libertarian, utilitarian, and other theories; and we defend a mixed use of
principles drawn from these theories.17
2. The Central Place of the Common Morality
An important part of the four-principles approach to biomedical ethics is
what Childress and I call common morality theory.18 From centuries of
experience we have learned that the human condition tends to deteriorate
into misery, confusion, violence, and distrust unless certain principles are
enforced through a public system of norms. Everyone living a moral life
15
The fair-opportunity principle descends from John Rawls’ principles of justice in A
Theory of Justice. Cambridge, MA: Harvard University Press: 1971; rev. ed., 1999: 60–67,
302–303 (1999: 52–58). Rawls (2001) later instructively restated, and partially reordered,
these principles, giving reasons for their revision, in Erin Kelly (ed.) Justice as Fairness:
A Restatement. Cambridge, MA: Harvard University Press: 42–43.
16
This general principle is developed in Madison Powers and Ruth Faden (2006). Social
Justice: The Moral Foundations of Public Health and Health Policy. New York: Oxford
University Press.
17
For diverse accounts of justice connected to biomedical ethics, see Norman Daniels
(2007). Just Health: Meeting Health Needs Fairly. New York: Cambridge University
Press; Madison Powers and Ruth Faden (2006). Social Justice: The Moral Foundations of
Public Health and Health Policy. New York: Oxford University Press; Amartya K. Sen
(2009). The Idea of Justice. London: Allen Lane.
18
Although there is only one universal common morality, there are various theories of the
common morality. For a diverse group of recent theories, see Alan Donagan (1977). The
Theory of Morality. Chicago: University of Chicago Press; Bernard Gert (2007). Common
Morality: Deciding What to Do. New York: Oxford University Press; Bernard Gert,
Charles M. Culver and K. Danner C̣louser (1997). Bioethics: A Return to Fundamentals,
2nd edn. New York: Oxford University Press.
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in any society is aware of the fundamental importance of moral standards
such as not lying, not stealing others’ property, keeping promises, respecting the rights of others, and not killing or causing harm to others. When
complied with, these shared norms lessen human misery and foster cooperation. These norms may not be necessary for the survival of a society,
as some have maintained,19 but it is not too much to claim that these
norms are necessary to ameliorate or counteract the tendency for the quality of people’s lives to worsen or for social relationships to disintegrate.20
The common morality is comprises full set of universal moral norms
shared by all persons committed to a moral way of life.21 Principlism is
constructed from this understanding of our common morality.
Some critics think that Childress and I hold that the four principles
themselves alone constitute the full set of universal norms. However, we
claim far less. We claim only that these principles we have identified and
put in the form of a framework for biomedical ethics are a part of universal morality. We selectively draw these principles from the common
morality in order to construct a normative framework for biomedical ethics. We have not sought a catalogue of universal morality’s contents — a
vast undertaking. The common morality we hold is consists of principles
(and rules), virtues, ideals, and rights — four critical types of norms for
understanding the common morality. I will now briefly discuss each of
these types.
19
See the sources referenced in Sissela Bok (1995). Common Values. Columbia, MO:
University of Missouri Press: 13–23, 50–59 (citing influential writers on the subject).
20
G. J. Warnock (1971). The Object of Morality. London; Methuen & Co. esp. 15–26;
John Mackie (1977). Ethics: Inventing Right and Wrong. London: Penguin: 107ff.
21
For useful critical assessments of principlist views about common morality theory and
its role; see Oliver Rauprich (2008). Common morality: Comment on Beauchamp and
Childress. Theoretical Medicine and Bioethics 29: 43–71, at 68; K. A. Wallace (2009).
Common morality and moral reform. Theoretical Medicine and Bioethics 30: 55–68; and
Ronald A. Lindsay (2005). Slaves, embryos, and non-human animals: Moral status and
the limitations of common morality theory. Kennedy Institute of Ethics Journal 15
(December): 323–346.
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2.1. Universal Principles and Rules of Obligation
I start with a few instances (not a complete catalogue) of universal principles and rules of obligation in the common morality. The following
examples are more concrete rules than the four abstract principles in the
framework presented above, but they still are parts of the common
morality: (i) Do not kill; (ii) Do not cause pain or suffering to others;
(iii) Prevent evil or harm from occurring; (iv) Rescue persons in danger;
(v) Tell the truth; (vi) Nurture the young and dependent; (vii) Keep your
promises; (viii) Do not steal; (ix) Do not punish the innocent; and
(x) Obey the law. These norms have been justified in various ways by
various philosophical theories, but I will not treat this problem of justification here.
2.2. Universal Virtues
The common morality also contains standards that are moral character
traits, or virtues. Examples are: (i) Honesty; (ii) Integrity; (iii) Nonmalevolence; (iv) Conscientiousness; (v) Trustworthiness; (vi) Fidelity;
(vii) Gratitude; (viii) Truthfulness; (ix) Lovingness; and (x) Kindness. The
virtues are universally admired traits,22 and a person is deficient in moral
character if he or she lacks these traits. Negative traits amounting to the
opposite of the virtues are vices (malevolence, dishonesty, lack of integrity,
cruelty, etc.). They are substantial moral defects, universally recognized as
such by persons committed to morality.
A number of scholars have criticized principlism on the grounds that
it neglects the virtues and virtue ethics, thus making principles the sole
prominent feature in the landscape of bioethics. This is a mis-assessment:
22
See Martha Nussbaum’s (1988) assessment that, in Aristotelian philosophy, certain
“non-relative virtues” are objective and universal: Non-relative virtues: An Aristotelian
approach, in Peter French et al. (eds.) Ethical Theory, Character, and Virtue. Notre Dame,
Ind.: University of Notre Dame Press: 32–53, especially 33–34, 46–50.
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Childress and I allocate a large segment of our analysis to the role of the
virtues in biomedical ethics.23
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2.3. Universally Praised Ideals
In addition to principles of obligation and virtues, moral ideals such as
charitable goals, community service, dedication to one’s job that
exceeds obligatory levels, and service to the poor are also a part of the
common morality. These aspirations are not required of persons, but
they are universally admired and praised in persons who accept and
act on them.24 Here are four examples that can be interpreted both as
ideals of virtuous character and ideals of action: (i) Exceptional forgiveness; (ii) Exceptional generosity; (iii) Exceptional compassion; and
(iv) Exceptional thoughtfulness.
2.4. Universal Rights
Finally, human rights form an important dimension of universal morality.
Rights are justified claims to something that individuals or groups can
legitimately assert against other individuals or groups. Human rights, in
particular, are those that all humans possess.25 Human rights language
easily crosses national and cultural boundaries and supports international
law and policy statements by international agencies and associations.
Although human rights are, for this reason, often interpreted as legal
rights, this interpretation does not properly capture their status. They are
universally valid moral claims, and they have been understood as such at
23
When we published the first edition of Principles of Biomedical Ethics, no one in
bioethics was then publishing on virtue ethics. We thought this type of theory was an
important and unduly neglected subject needing to be brought into the field, especially
in light of the history of medical ethics, where the virtues were once prominent in various
codes and writings.
24
See Gert (2007), op. cit., 20–26, 76–77; Richard B. Brandt (1992). Morality and Its
Critics, in his Morality, Utilitarianism, and Rights. Cambridge: Cambridge University
Press: chap. 5.
25
Cf. Joel Feinberg (1980). Rights, Justice, and the Bounds of Liberty. Princeton, NJ:
Princeton University Press: esp. 139–141, 149–155, 159–160, 187; See also Alan Gewirth
(1996). The Community of Rights. Chicago: University of Chicago Press: 8–9.
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The Principles of Biomedical Ethics 107
least since early modern theories of rights were developed in the 17th
century.
I defend a strict version of the thesis that rights and obligations are
correlative. The correlativity thesis asserts that in all contexts of rights —
moral and legal — a system of norms imposes an obligation to act or to
refrain from acting so that relevant parties are enabled either to perform
some action or to have some good or service provided to them. The language of rights is thus always translatable into the language of obligations: A right entails an obligation, and an obligation entails a right.
Obligations without fail imply corresponding rights if they are bona fide
moral obligations, in contrast to merely self-assumed obligations or personal moral ideals, such as “obligations” of charitable giving.26 If, for
example, a society has an obligation to provide goods such as health care
to needy citizens, then any citizen who meets the relevant criteria of need
has a right to the available healthcare. All universal principles in this way
entail universally valid rights claims. I will return to the connection
between principles and moral rights in a later section.
3. Particular Moralities, Moral Pluralism,
and Moral Relativism
A persistent question from critics of my views about principles has been
concerned with whether the four principles are truly universal. Perhaps
they are merely local — e.g. western or American. My emphasis on universal morality also might lead one to think that I do not allow for any
form of moral pluralism or for local moral viewpoints — as if morality
were a monolithic whole that does not permit disagreements and differences of approach. However, this is a misunderstanding of the connection
between universal morality and the moral norms that are particular to
cultures, groups, and individuals. Unlike the common morality, with its
abstract and content-thin norms, particular moralities present concrete,
non-universal, and content-rich norms.
26
So-called imperfect obligations are moral ideals that allow for discretion in my account.
Cf. the somewhat similar conclusions in Feinberg (1980), op. cit., 138–139, 143–144,
148–149.
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Particular moralities include the many responsibilities, ideals, attitudes, and sensitivities found in, for example, cultural traditions, religious
ethics, and professional guidelines. The reason why norms in particular
moralities, including customary moralities, often differ is that the universal
starting points in the common morality — its basic principles — can be
legitimately developed and specified in different ways to create different
guidelines and procedures.
Nonetheless — and this is a key matter in understanding why a moral
relativism of principles is an unacceptable theory — all justified particular moralities share the norms of the common morality with all other
justified particular moralities. That is, all justified particular moralities,
without exception, share universal morality. Moral pluralists sometimes
seem to claim that there are multiple concepts of morality in the normative
sense, and therefore that there are multiple normative moralities. There
are, of course, multiple moralities in the descriptive sense of “morality.”27
In the descriptive sense, “morality” refers to groups’ codes of conduct.
This descriptive sense has no implications for how all persons should
behave. Moralities can differ extensively in the content of their beliefs and
in their practice standards. One society might heavily emphasize the liberty of individuals, another, the sanctity of human and animal life over
liberty. One society may have established rituals disavowed in another.
What is unacceptable in one society might be condoned in another. To let
a seriously ill individual die when that person requests shutting down a
respirator that sustains the person’s life is unacceptable in some societies
or institutions, while judged acceptable in others.
In the normative sense of “morality,” by contrast, empirical claims
about moral belief are not the subject matter. Rather, principles or judgments state what is morally correct under the concept of morality. As
stated by Philippa Foot regarding this view, “A moral system [has normative] … starting-points … fixed by the concept of morality.… They belong
to the concept of morality — to the definition and not to some definition
which a man can choose for himself.”28 Moral pluralism, then, is a
27
On this distinction see Bernard Gert (2002). The Definition of Morality. The Stanford
Encyclopedia of Philosophy. Available online via http://plato.stanford.edu/entries/moralitydefinition/(retrieved on 11 February 2008).
28
Philippa Foot (2002). Moral Dilemmas. Oxford: Oxford University Press: 6–7. Peter
Herissone-Kelly guided me to this passage.
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The Principles of Biomedical Ethics 109
group-relative notion best interpreted as a version of “morality” in the
descriptive sense — that is, as a sociological report on particular moralities. It would be incoherent to formulate the normative meaning of the
term morality as consisting of the norms of multiple moralities with conflicting rules, because morality would, thus, give contradictory advice.
I also caution against an undue emphasis on differences among moral
theories that seem to amount to a pluralism of theory. Disagreements in
theory are usually about the theoretical foundations of morality. Hence,
they may mask an underlying and abiding agreement about central considered moral judgments and basic principles. Theoreticians tend to
assume, rather than disagree about our deepest moral principles (e.g. prohibiting the breaking of promises, requiring that we not cause harm to
others, requiring respect for autonomous choice, etc.). Put another way,
many philosophers with different conceptions of the theoretical justification of universal morality do not significantly disagree on the substantive
principles, rules, ideals, and virtues that comprise the common morality.
4. The Specification of Norms and the Preservation
of Moral Coherence
To say that moral principles have their origins in and find support in the
common morality is not to say that their appearance in a well-developed
system of biomedical ethics is identical to the norms of the common
morality. Principles underdetermine the content of moral judgments
because abstract principles have too little content to determine all needed
rules and practical judgments. All abstract norms must be carefully
defined and then tailored to give specific guidance regarding, for example,
how much information must be disclosed, how to maintain confidentiality,
when and how to obtain an informed consent, and the like.
General principles must be made specific if they are to become practical. The same is true of laws: If a law is too general, then it will not be a
practical instrument. Further legislation would be needed.29 Specification in
morals is a process of adding action-guiding content to general principles.
29
For an excellent study of how the four-principles approach can and should be used as a
practical instrument; see John-Stewart Gordon, Oliver Rauprich and Jochen Vollman
(2011). Applying the four-principle approach. Bioethics 25: 293–300, with a reply by Tom
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Specification is not a process of either producing or defending general
principles such as those in the common morality. Specification starts only
after they are available. Specifying the norms with which one starts,
whether those in the common morality or norms that were previously
specified, is accomplished by narrowing the scope of the norms, not by
explaining what the general norms mean.30 As Henry Richardson puts it,
specification occurs by “spelling out where, when, why, how, by what
means, to whom, or by whom the action is to be done or avoided.”31
For example, a possible specification of “respect the autonomy of
persons” is “respect the autonomy of competent patients when they
become incompetent by following their advance directives.” This specification works well in some medical contexts but will not be adequate in
others, which leaves a need for additional specification. Progressive
specification may need to be continued indefinitely, gradually reducing
the conflicts of norms that abstract principles themselves cannot resolve.
To qualify all along the way as a specification, a transparent connection
must continuously be maintained to the initial norm that gives moral
authority to the resulting string of specified norms.
More than one line of specification of principles is commonly available when confronting practical problems and moral disagreements.
Different persons or groups may justifiably offer conflicting specifications. It is an inescapable part of the moral life that different persons and
groups will offer different, sometimes conflicting, specifications, thus
potentially creating multiple particular moralities. On deeply problematic
Beauchamp (2011). Making principlism practical: A commentary on Gordon, Rauprich,
and Vollmann. Bioethics 25: 301–303.
30
Henry S. Richardson (1990). Specifying norms as a way to resolve concrete ethical
problems. Philosophy and Public Affairs 19: 279–310; and Specifying, balancing,
and interpreting bioethical principles, in James F. Childress, Eric M. Meslin, and Harold T.
Shapiro (eds.). Belmont Revisited: Ethical Principles for Research with Human Subjects.
Washington, DC: Georgetown University Press: 205–227; David DeGrazia (1992).
Moving forward in bioethical theory: Theories, cases, and specified principlism. Journal
of Medicine and Philosophy 17: 511–539; and David DeGrazia and Tom L. Beauchamp
(2001). Philosophical foundations and philosophical methods, in D. Sulmasy and J. Sugarman
(eds.). Methods of Bioethics. Washington, DC: Georgetown University Press: esp. 33–36.
31
Richardson (2005), op. cit., 289.
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issues such as abortion, animal research, aid in disaster relief, health
inequities, and euthanasia, competing specifications will be offered even
by reasonable and fair-minded parties committed to the common morality.
4.1. Examples of Particular Moralities and Their Specifications
Professional moralities such as those in biomedical research, medical
practice, nursing practice, and veterinary practice are good examples of
particular moralities that contain at least some specifications not found
in other particular moralities. Medical moral codes, declarations, and
standards of practice often legitimately vary from other medical moralities in the ways they handle justice in access to healthcare, human rights,
justified waivers of informed consent, government oversight of research
involving human subjects, privacy provisions, and the like. Both
approaches can be justified if they coherently specify universal
morality — that is, if they specify the universal principles that form the
core of the common morality.
Other examples of particular moralities that contain differing specifications are religious moralities. Religious traditions may have multiple
moralities within the spread of a single religious faith. So-called Protestant
Christianity is an example. Each sect of Protestant Christianity (Lutherans,
Presbyterians, Methodists, Episcopalians, etc.) can deviate in the specification of its own code of ethics. They share the common morality, but they
do not share whatever makes each one distinctively the religious group it
is in its moral outlooks. As with any particular morality distinctive to a
tradition, a religious group will state what is permissible and impermissible and what is obligatory and non-obligatory.
A distinctive religious morality, being a particular morality, often has
no capacity to reach out into a public arena of discussion in a pluralistic
society; that is, public policy cannot in a pluralistic context be fixed
purely by appeal to the norms of a particular religious morality. For
example, if this morality requires prayers before all public meetings, it
cannot expect that this rule is suitable to govern those in society who do
not share this belief and practice. This limitation could be considered a
disadvantage inherent in particular moralities as they operate in pluralistic societies.
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However, I want to be emphatic about the point that very significant
advantages are found in a well-specified religious morality. The common
morality — being general and only general — does not have and cannot
have the same richness and specificity that a particular morality does.
Moreover, a particular morality does not forego universal morality; it
retains and is governed by universal morality. These are great advantages
for particular moralities.
An interesting example of specification is found in some comments
made by Professor Ali Al-Qaradaghi when he discusses patient’s permission for a necessary medical intervention. He mentions that, “The patient’s
permission of the treatment is essential if the patient is in full legal capacity to give it. If he is not, the permission of his (or her) legal guardian shall
be sought according to the order of guardianship in Sharia.” The “in
Sharia” specification is noteworthy. The points he makes about both
required permission and guardian authority is in effect a universally
observed rule today in biomedical ethics, just as informed consent is.
What the language of “in Sharia” adds here is how, in a particular morality, the guardianship matter is to be determined. Those who follow Sharia
law know, as a result of this specification, how it is determined who will
be the guardian in any given case. This specification is a guardianshipselection rule. Every particular medical morality will have such a rule of
guardianship specification, and quite legitimately so, even though the
connected rules of permission and guardianship are universal.
A second rule mentioned in this same context of discussion by the
Professor is, “In emergency cases, when the life of the victim is in danger,
medical treatment shall not depend on permission.” This is a de facto
universal rule in clinical ethics that is not placed in a context of a particular morality. All medical moralities now accept this principle.
4.2. Justifying Specifications Using a Method of Coherence
Since there can be numerous specifications, the question arises of what
justifies some specifications and does not justify others. A specification is
justified, in my account, if and only if it is consistent with (does not violate) the norms of common morality and maximizes the coherence of the
overall set of relevant, justified beliefs of the party doing the specification.
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The Principles of Biomedical Ethics 113
These beliefs could include empirically justified beliefs, justified basic
moral beliefs, and previously justified specifications. This position is a
version of the philosophical account of method, justification, and theoryconstruction in ethics known as wide reflective equilibrium.32 This theory
holds that justification in ethics occurs through a reflective testing of
moral beliefs, moral principles, and theoretical postulates with the goal of
making them as coherent as possible. The goal of any given specification
is to achieve an equilibrium while also resolving a contingent conflict of
principles.
This method demands assessment of the strengths and weaknesses of
the full body of all relevant and impartially formulated judgments, principles, theories, and facts (hence the “wide” scope of the account). Moral
views to be included are beliefs about particular cases, about rules and
principles, about virtue and character, about consequentialist and nonconsequentialist forms of justification, about the role of moral sentiments,
and so forth. The resultant moral and political norms can then be tested in
a variety of previously unexamined circumstances to see if incoherent
results emerge. If incoherence arises, conflicting norms must be adjusted
to the point of coherence.
Achieving a state of reflective equilibrium in which all beliefs fit
together coherently, with no residual conflicts or incoherence, is an ideal
that will not be comprehensively realized by anyone. A stable equilibrium
in the full set of one’s moral and political beliefs is an unrealistic goal. We
can only expect conscientious approximation of the ideal. There is no
reason to expect that the process of rendering norms coherent by specification will ever come to an end or be perfected. However, this ideal is not
a utopian theory toward which no progress can be made. Particular
moralities (of individuals and groups) are, from this perspective, works
32
Norman Daniels (1996). Wide reflective equilibrium in practice, in L.W. Sumner and
J. Boyle (eds.). Philosophical Perspectives on Bioethics. Toronto: University of Toronto
Press: 96–114; John D. Arras (2007). The way we reason now: Reflective equilibrium in
bioethics, in Bonnie Steinbock, (ed.). The Oxford Handbook of Bioethics. Oxford: Oxford
University Press: 46–71; Carson Strong (2010). Theoretical and practical problems with
wide reflective equilibrium in bioethics. Theoretical Medicine and Bioethics 31: 123–140;
Norman Daniels (1996). Justice and Justification: Reflective Equilibrium in Theory and
Practice. New York: Cambridge University Press; Norman Daniels (2003). Reflective
Equilibrium, Stanford Encyclopedia of Philosophy (retrieved 24 August 2007).
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continuously in progress, a process of improvement rather than a finished
product. Moralities can be rendered coherent in more than one way
through the process of specification.
To take an example from the ethics of the distribution of organs for
transplantation, imagine that an institution has used and continues to be
attracted to two policies, each of which rests on a basic rule: (i) distribute
organs by expected number of years of survival (to maximize the beneficial outcome of the procedure), and (ii) distribute organs by using a waiting list (to give every candidate an equal opportunity). These two
distributive principles are inconsistent and need to be brought into equilibrium in the institution’s policies. Both can be retained in a system of
fair distribution if coherent limits are placed on the norms. For example,
organs could be distributed by expected years of survival to persons 65
years of age and older, and organs could be distributed by a waiting list
for 64 years of age and younger. Proponents of such a policy would need
to justify and render, as specifically as possible, their reasons for these two
different commitments. Such proposals need to be made internally coherent in the system of distribution and also need to be made coherent with
all other principles and rules pertaining to distribution, such as norms
regarding discrimination against the elderly and fair payment schemes for
expensive medical procedures.
5. Human Rights and Multiculturalism
Confusion continues to be plentiful regarding differences in Eastern and
Western cultures and about the role, if any, that universal principles play in
making judgments about moral claims made in different moral traditions. In
my view, little supports the commonly reported thesis that the East — that
is, Asia — has fundamentally different moral traditions of liberty, rights,
respect for autonomy, and respect for families from those in the West — that
is, Europe and the Americas. I will concentrate in my comments on the
universal norms of morality, and in particular on human rights.
5.1. Human Rights and Universal Principles
The view that I take of cultural differences and basic principles is notably
similar to Amartya Sen’s in his monograph on “Human Rights and Asian
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The Principles of Biomedical Ethics 115
Values.”33 Sen is, of course, from India, and so his personal history of
moral beliefs presumably descends from an Eastern culture. But Sen
wholly rejects the way Eastern views are commonly presented, in parts of
both the East and the West, especially regarding freedom and human
rights. He points out that “no quintessential [moral] values … differentiate
Asians as a group from people in the rest of the world.” He finds that the
major constituent components of universally valid ideas of liberty and
basic rights of liberty, especially political liberty, are found in both
Eastern and Western traditions, even though the idea of human rights is
relatively new to all parts of the world. The claim that these ideas are
friendly to Western tradition and alien to Eastern traditions he finds “hard
to make any sense of.” I completely agree.
I do not mean that a principle such as respect for individual autonomy is given precisely the same status and prized to the same extent in
Eastern traditions as it might be in some Western cultures. Many populations in the East may legitimately prioritize community and relationships
over individual autonomy and cultural independence to a higher degree
than do many populations in the West. But this thesis does not entail that
Eastern populations deprecate or reject human rights of individual autonomy or that they disvalue political liberty. Nor does it indicate that
Western populations deprecate community and relationships. These
claims are fundamentally myths about differences between the East and
the West.
Research ethics is an interesting area in which the universal reach of
some principles is now globally acknowledged. Around 40 years ago there
were no universally accepted principles of research ethics, but today we
see a vast similarity, in countries on every continent, in codes, laws, and
regulations governing research with human subjects. There are some
understandable and justifiable differences from country to country, but the
differences pale in comparison to the similarities in the shared moral principles and legal norms governing how biomedical research can and cannot
be conducted. Rules of informed consent — which were only a few years
ago deeply questioned or simply not discussed in various cultures — are
now universally accepted. Here are a few steeply abridged examples of
33
Amartya Sen (1997). Human Rights and Asian Values. New York: Carnegie Council,
with an Introduction by Joel H. Rosenthal, esp. 10, 13, 17, 27, 30.
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the principles of research ethics that are globally accepted (and violations
of them universally condemned):
• Disclose all material information to subjects of research.
• Obtain a voluntary, informed consent to medical interventions.
• Maintain secure safeguards for keeping personal information about
subjects private and confidential.
• Receive surrogate consent from a legally authorized representative for
incompetent subjects.
• Ethics review committees must scrutinize and approve research
protocols.
• Research cannot be conducted unless its risks and intended benefits are
reasonably balanced, and risks must be reduced to avoid excessive risk.
• Special justification is required if proposed research subjects are vulnerable persons.
These norms of the obligations of researchers and sponsors all have
correlative human rights that protect research subjects.34
A Final Point about Universal Morality
Professor Ali Al-Qaradaghi comments that in using the language of
“biomedical ethics,”
[Beauchamp] refers here to the beginning of those four principles as a
structured framework and the appearance of writings that focused on
interpreting and explaining them. Actually the history of ethics, including medical ethics, is quite old and they are extracted from the ethical
values taught by the heavenly religions; namely Judaism, Christianity,
and Islam.
34
See, as examples of international documents that can easily be so interpreted, the World
Medical Association’s Declaration of Helsinki, 2008 revision, “Declaration of Helsinki:
Ethical Principles for Medical Research Involving Human Subjects,” Part B, “Basic
Principles for all Medical Research” (first adopted 1964 and currently under revision);
Council for International Organization of Medical Science (CIOMS), in collaboration with
the World Health Organization (WHO), International Ethical Guidelines for Biomedical
Research Involving Human Subjects (Geneva: CIOMS 2002) (currently under revision).
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The Principles of Biomedical Ethics 117
The Professor is both right and wrong here. Biomedical ethics did not
exist until its origins in roughly the last half of the 20th century. The
ancient traditions were all about medical — not biomedical ethics. Ancient
views of medical ethics were literally from a different world lacking
medical science. Also, I was not referring to “the beginning of th[e] four
principles.” I meant only to refer to changes that occurred in the 20th
century that led us away from an outmoded Hippocratic medical ethics to
a biomedical ethics.
However — and this is an important point to me — when I use the
language of the common morality I do mean to include ancient moral
traditions, including what the Professor refers to as “the heavenly religions.” These anciently formed traditions do not represent biomedical
ethics; but they are excellent representatives of the common morality.
Likewise, the four principles I defend are part of the common morality.
These four principles are not inherently created for biomedical ethics;
they must be made suitable for that context and specified. That is, that
they are not biomedical principles until they are specifically embedded in
a biomedical context is what Childress and I have tried to show.
5.2. Multiculturalism as a Theory of Universal Principles
I return now to my earlier observations about particular moralities, pluralism, and relativism. It is an undisputed fact that multiple cultures have
constructed unique, particular moralities. This fact suggests to some writers in bioethics that we live in a multicultural world in which diverse
particular moral cultures can live together peacefully, without need for
the notion of universal, basic principles. However, this characterization
has matters upside down. Multiculturalism is not a pluralism or a relativism. It is a theory of universal principles to the effect that particular
moralities are owed respect because morality demands it. The term “multicultural world” has been hijacked by some writers in bioethics to suggest the reverse and especially to suggest that there is no commonly held
morality.35
35
Examples are H. Tristram Engelhardt Jr. (1996). The Foundations of Bioethics, 2nd edn.
New York: Oxford University Press; Robert Baker (1998). A theory of international
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“Multiculturalism,” properly used, refers to a type of theory that
supports the moral principle that cultural or group traditions, institutions,
perspectives, and practices should be respected and should not be violated
or oppressed as long as they do not themselves violate the standards of
universal morality. The objective of multiculturalism is to provide a theory of the norms that suitably protect vulnerable groups when they are
threatened with marginalization and oppression caused by one or more
dominant cultures. Resistance to forceful dominance and cultural oppression are the motivating forces of multiculturalist theory, which holds that
respect is owed to people of dissimilar but peaceful cultural traditions
because it is unjust and disrespectful to marginalize, oppress, or dominate
persons merely because they are of an unlike culture or subculture. The
moral notions at work in multicultural theory are universal-principle
driven theses about rights, justice, respect, and non-oppression.36 Without
universal norms of toleration, respect, restraint, and the like, a multiculturalist could neither explain nor justify multiculturalism.
5.3. Are Principles a Disguised Form of Cultural Imperialism?
Some may think that my support of transcendent, universal moral standards is merely a disguised form of cultural imperialism. Persons outside
of a given culture who press for recognition within that culture of the
human rights of women, minorities, children, the ill, the disabled, the
oppressed, the marginalized, the economically disadvantaged, and other
vulnerable groups have often been denounced as cultural imperialists who
incorporate their own values, which are uncritically assumed to be universally valid, but that — beneath the veneer of fairness, equity, and
respect — camouflage the continuance of some form of dominance.
bioethics: Multiculturalism, postmodernism, and the bankruptcy of fundamentalism.
Kennedy Institute of Ethics Journal 8: 201–231; Leigh Turner (2003). Bioethics in a
multicultural world: Medicine and morality in pluralistic settings. Health Care Analysis
11: 99–117.
36
Compare the essays in Robert K. Fullinwider (ed.) (1996). Public Education in a
Multicultural Society. Cambridge: Cambridge University Press; and Amy Gutmann (ed.)
(1992). Multiculturalism and “The Politics of Recognition”. Princeton NJ: Princeton
University Press.
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The Principles of Biomedical Ethics 119
The real problem here is that virtually every region of the world has
experienced a horrid history of imperialistic control extending from one
people to another, whether from west to east, within regions, or within the
borders of a single nation. Numerous cultural traditions, past and present,
and in all parts of the world, have held that their values are universal values to which everyone must conform. They all deserve condemnation.
6. Conclusion
I have argued in defense of the four-principles approach to biomedical
ethics, now increasingly called principlism. My arguments move to the
conclusion that a universal set of moral principles comprises the common
morality and that the four clusters of principles of biomedical ethics are
part of, but not the whole of, the common morality that all morally committed persons share. Although the content of these norms is thin, owing
to their abstractness, they create a wall of moral standards that cannot
justifiably be violated in any culture or by any group or individual. They
give us our moral compass and are our ultimate bulwark against a descent
into relativism.
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Response by Ali Al-Qaradaghi
to Tom Beauchamp’s Paper
Ali Al-Qaradaghi
This chapter is a response to the research presented by Tom Beauchamp
regarding The Four Principles of Biomedical Ethics. The methodology
adopted by the chapter will be an examination of these principles so as to
determine their legal foundation, historical background, and the extent to
which they can be considered comprehensive principles. This examination will be framed within an objective, constructive discussion aiming to
achieve the goals of benefit and excellence as outlined by the research
Center for Islamic Legislation and Ethics (CILE).
The four principles of biomedical ethics according to Beauchamp are:
(a) Respect for Autonomy
This principle is concerned with the patient. It is defined as a person’s free
will and freedom of choice without any interference from other persons.
Beauchamp outlines two conditions for autonomy: “liberty (the absence
of controlling influences)” and “agency (self-initiated intentional action).”1
It means that the patient is free to accept or refuse certain medication and
1
Tom Beauchamp (2016). The Principles of Biomedical Ethics as Universal Principles,
included in this volume. Singapore: World Scientific.
121
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requires that a physician respects the requests made by the patient, if he is
able to, or by his family on his behalf. Despite the ethical issues that arise
in situations where a patient refuses a necessary medical intervention, the
principlist approach prioritizes respect for autonomy over other ethical
principles. However, Beauchamp states that this prioritization may be
dismissed in certain cases. He explains, “Many kinds of competing moral
considerations can validly override respect for autonomy under conditions
of a contingent conflict of norms. For example, if our choices endanger
the public health, potentially harm innocent others, or require a scarce and
unfunded resource, exercises of autonomy can justifiably be restrained or
overridden.”2
Given this clarification, it becomes clear that this is not an absolute
principle and is not applicable in all cases. Rather, it is more of a general
rule that is susceptible to exceptions that also require clearly defined
guidelines. The guidelines for these exceptional cases were outlined by
the International Islamic Fiqh Academy (IIFA), affiliated with the
Organization of Islamic Cooperation (OIC), in its resolution no. 69/5/7.
The exceptional cases as identified by the resolution are: infectious diseases, caesarian operations for saving the life of a newborn baby even if
the mother and her husband refuse the operation, and accidents during
which a patient has lost consciousness.3
(b) Nonmaleficence
This principle refers to the prevention of harm and injury and is associated
with the Hippocratic medical ethics according to the mandate, “Above all
[or first] do no harm.” This principle is also included in the Hippocratic
Oath. The principle of nonmaleficence establishes a variety of specific
ethical rules, among which are:
(i) “Don’t kill.”
(ii) “Don’t cause pain or suffering to others.”
(iii) “Don’t incapacitate others.”
2
3
Ibid.
See International Islamic Fiqh Academy 3(7): 731–733.
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In this regard, Beauchamp quotes the British physician Thomas
Percival, who asserted that, “a principle of nonmaleficence fixes the physician’s primary obligations and triumphs even over respect for the
patient’s autonomy in a circumstance of potential harm to patients.”4
(c) Beneficence
This principle refers to the promotion of good. Beauchamp acknowledges
that the line between that which is demanded under the principle of
beneficence and that which is not is undoubtedly difficult to draw. In fact,
it is deemed impossible to draw a precise line under this principle without
considering the particulars of different contexts.5 There have been many
contentious debates arguing for the sufficiency of the principle of nonmaleficence and the possibility of it replacing the principle of beneficence.
However, Beauchamp rejects this proposition, arguing that a physician’s
commitment to preventing harm cannot be merged with his commitment
to providing them with care. An example of the first would be preventing
murder or disablement while the latter involves advancing the interests of
people.6 On the other hand, one can argue that the principle of beneficence implies that of nonmaleficence and preventing harm, as will be
discussed later.
(d) Justice
Justice in this context refers to the fair distribution of health care and its
costs within societies. It also refers to the fair opportunity principle.7
Given this understanding, this principle primarily addresses governments
rather than physicians.
After reviewing each of these points, I can honestly say that this is a
very well-written research paper serving to elaborate on the four principles of biomedical ethics as developed by Tom Beauchamp and James
4
See Beauchamp (2016), op. cit.
Ibid.
6
Ibid.
7
Ibid.
5
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Childress since 1976 and to this day. There is no exaggeration in stating
that it is invaluable research. Therefore, I merely have a few clarifying
points to add with the purpose of providing an Islamic foundation to these
principles which, as outlined in my distinct chapter, will lead to the development of a comprehensive theory that is compatible with Islamic values
and principles.
1. A Historical Perspective
In introducing the origin of biomedical ethics, Dr. Beauchamp states,
“Principles that can be understood with relative ease by the members of
various disciplines figured prominently in the early developments in the
history of biomedical ethics during the 1970s and early 1980s.”8 In this
regard, I believe Dr. Beauchamp is referring specifically to the emergence
of these four principles as a structured framework and the appearance of
writings that focused on interpreting, explaining, and connecting them.
However, the history of ethics (including medical ethics) is rather ancient
and can be traced back to the ethical values taught by the heavenly religions, namely Judaism, Christianity, and Islam, notwithstanding slight
discrepancies in details, foundations, and terminology. Moreover, the
presence of general ethical principles can be found across several ancient
civilizations, such as the Pharaonic Civilization, Hamurabi’s Code of
Laws, ancient Greek philosophy, and Buddhist and Hindu civilizations.
For example, in the Ancient Egyptian civilization, the Book of the
Dead mentions that a dead person is brought to stand in front of the God
Osiris. The dead person then justifies his actions saying, “I come to you
my lord in submission to witness your magnificence; I come bearing truth
and abandoning dishonesty, for I have never been unjust towards another
and have avoided the path of those gone astray.” He then accounts that he
was never disobedient, nor a liar, nor harmful to others, nor committed or
assisted with murder, nor a thief, nor committed adultery or embezzlement, nor violated the sanctity of death, nor cheated in trade. He then
states, “I am pure, I am pure, I am pure, and as long as I am innocent of
8
Ibid.
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sin, place me amongst the victorious my Lord.”9 Other similar examples
include Hamurabi’s Code of Law, the Hippocratic Oath and the Islamic
Oath.10
2. The Source and Authority of Ethics
The argument for the importance of ethics in general, and that of medical
ethics in particular, is eloquently presented by Dr. Beauchamp. He
explains, “If some principles were dropped from the framework, the
demands of the moral life would not be what we know those demands to
be, just as a landscape would not be the same landscape if certain rocks,
trees, or plants were removed from it.”11 He also adds,
From centuries of experience we have learned that the human condition
tends to deteriorate into misery, confusion, violence, and distrust unless
certain principles are enforced through a public system of norms.
Everyone living a moral life in any society is aware of the fundamental
importance of moral standards such as not lying, not stealing others’
property, keeping promises, respecting the rights of others, and not killing or causing harm to others. When complied with, these shared norms
lessen human misery and foster cooperation. These norms may not be
necessary for the survival of a society, as some have maintained, but it
is not too much to claim that these norms are necessary to ameliorate or
counteract the tendency for the quality of people’s lives to worsen or for
social relationships to disintegrate.12
While Dr. Beauchamp emphasized the importance of ethics as well as
the four principles, he considered ethics to be the source from which
9
See Mohammed Ali Al-Bar (2010). Ethics: Its Religious Fundamentals and Its
Philosophical Roots (Al-akhlāq: uūluhā al-dīnīyah wa-judhūruhā al-falsafīyah). Kunuz
Al-Ma‘arif: 62.
10
See Encyclopedia Britannica (1982), 15th edn. vol. 4, 878; Ibn Abi Usaybi‘ah (1995).
The Best Accounts of the Biographies of Physicians (‘Uyūn Al-anbā’ Fītabaqāt Al-atibbā’)
Beirut: Maktabat Al-Hayat, 1965: 45.
11
Beauchamp (2016), op. cit.
12
Ibid.
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adherence to the four principles emerges. In this regard he wrote, “All
principles can in some contexts be justifiably overridden by other moral
norms with which they come into contingent conflict.”13 I argue that the
practice and impact of morality will be undermined if commitment to
moral principles is contingent merely on ethical obligation. In fact, the
foundational commitment to these principles as presented in Beauchamp’s
paper appears weak and fragile. The reason for this lies in the fact that
Beauchamp, as well as other moral philosophers, founded their moral
theory on utilitarianism without taking religious aspects into consideration.
This means that in situations where ethics conflict with certain economic
interests prohibited by Islam and other religions (such as alcohol), priority
is given to those interests over religion despite their negative social impact
outweighing their benefits. As God explains, “They ask you about wine
and gambling. Say, ‘In them is great sin and [yet, some] benefit for people.
But their sin is greater than their benefit’…” (Qur’an 2:219).
It is well known that the most resolute commitments arise from religious obligation and legislation. Otherwise, we would have to rely on the
integrity of a person’s conscience, which can be rather volatile. All in all,
if a person is not driven by a fear of God and hope for His reward, he will
easily be tempted to pursue his own personal interests and will most likely
prioritize his own interests above others. It is quite likely that he will surrender to his whims, desires, and individualistic perspective, which, as
often seen, has led to the strangest outcomes due to people’s lack of piety,
fear of God, and negligence of the Day of Judgment.
2.1. Violations Associated with the “Active Conscience”
Slogan
Below is an example demonstrating that conscience alone is insufficient
to ensure moral commitment and that strong religious endorsement and
legislation is necessary.
Beauchamp and Childress emphasize in their book Principles of
Biomedical Ethics the fact that African-Americans suffering from hypertension should not be treated in a hospital’s Casualty Department if they
do not have medical insurance. They argue that several researchers have
13
Ibid.
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Response by Ali Al-Qaradaghi 127
found that poor patients with such circumstances will be unable to continue
or follow-up their medication due to the absence of a family physician or
their lack of medical insurance. Hence, they consider treating them to be a
waste of time, effort and money.14 As stated by Dr. Mohammed Ali Al-Bar,
both Beauchamp and Childress agree, without explicitly stating so, that
these patients should be left to suffer and die from their hypertension or its
sequelae e.g. strokes, heart attacks, heart failure, and kidney failure.
If this is the view supported by the authors of Principles of Biomedical
Ethics, what is to be expected from those who do not concern themselves
with writing about ethics? Rather, what was expected from these two
ethicists was a criticism of the unjust American healthcare system that
excludes 50 million citizens from the right to medical treatment, especially given that America was not suffering from a financial crisis at that
time and, in fact, was one of the world’s richest countries. It is truly
intriguing, on the other hand, to find that Cuba, America’s poorer neighbor, provides free medical insurance not only to its citizens, but also to
those visiting Cuba.15 In addition, great deals of serious ethical violations
have been taking place since 1915 and to this day, indicating a prevalent
lack of morality in experiments conducted by hospitals, pharmaceutical
companies, and other institutions.16
Sincere belief (īmān), on the other hand, establishes God-consciousness
(taqwá), fear of God, a desire for His reward, and constant awareness of
God’s watchfulness in all situations. This belief serves as a genuine internal incentive for a person to observe good deeds and avoid harming
others. It is described as a state of iḥsān, which follows the stages of īmān
(sincere belief) and Islam. As explained by the Prophet — may the peace
and blessings of God be upon him (PBUH) — in the authentic tradition,
“Iḥsān is to worship God as if you see Him, and if you do not achieve this
state of devotion, then (take it for granted that) God sees you.”17
14
Tom Beauchamp and James Childress (1979). Principles of Biomedical Ethics. Oxford:
Oxford University Press: 347–348, footnote 8.
15
Ibid.
16
Ibid.
17
Taken from a hadith reported by Bukhari, Book of Iman, no. 4777 and Muslim, Book
of Iman, no. 9 on the authority of Abu Hurayrah.
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3. Are The Four Principles All-inclusive
and Restrictive?
The four principles of biomedical ethics are not representative of all common morality and not based on complete induction. Rather, they form a
part of a larger moral framework. Beauchamp acknowledges this (as does
Childress in their coauthored book), stating in his research, “Some critics
think that Childress and I hold that the four principles constitute the full
set of universal norms. However, we claim far less. We claim only that
these principles we have identified and put in the form of a framework for
biomedical ethics are a part of universal morality. We selectively draw
these principles from the common morality in order to construct a normative framework for biomedical ethics.”18
Therefore, these principles are neither comprehensive nor precursory.
Instead, they are founded on this larger framework whose very structure
is debatable. For instance, whereas justice is included as one of the four
principles, the question arises as to why equal treatment of all patients is
not included as a principle. Equality is arguably just as significant a principle serving to prevent discrimination based on aspects such as wealth,
race, etc. Likewise, there are countless other ethical principles that may be
considered worthy of inclusion in the framework of biomedical principles.
These include principles such as loyalty towards a physician’s teachers
and mentors — as included in the Hippocratic and Islamic Oath — and
honesty, transparency, keeping promises, and upholding contracts.
It is worth noting that, as acknowledged by both Beauchamp and
Childress, these principles are merely an attempt at constructing a normative framework for biomedical ethics and are not intended to encompass
all morals, values, and ideals. Nonetheless, these are truly admirable
efforts leading to a positive attempt, although there remains a need for
further discussion and critique.
3.1. The Distinction between Principles and Common Morality
Prior to discussing this topic, it must be noted that Beauchamp differentiates between the four principles and common morality. He defines the
18
Beauchamp (2016), op. cit.
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Response by Ali Al-Qaradaghi 129
four principles as the normative framework for biomedical ethics and
common morality as that which encompasses several other rules and values such as: “(i) Do not kill; (ii) Do not cause pain or suffering to others;
(iii) Prevent evil or harm from occurring; (iv) Rescue persons in danger;
(v) Tell the truth; (vi) Nurture the young and dependent; (vii) Keep your
promises; (viii) Do not steal; (ix) Do not punish the innocent; and
(x) Obey the law.”19 Given this distinction, we can confidently say that the
four principles do not cover the range of morals, values, and religious and
human ideals. In fact, the method through which certain ethics are categorized as principles while others are not is in itself debatable and subject to
ongoing discussion.
On a different note, it may be acceptable to conflate nonmaleficence
and beneficence under the single principle of beneficence, which is
defined as promoting good. This definition implies one’s avoidance of
causing harm to others. In regards to this issue, some scholars of Islamic
jurisprudence have indeed categorized preventing harm under the principle of interests (malaah) since this prevention is in itself a benefit and
seeks to advance interests. In turn, the two principles are considered
synonymous.
4. Physician’s Internal Morality
The four principles afford little attention to the development of the physician’s internal morality. As demonstrated earlier, their concern is primarily
with external actions and behaviors. Needless to say, it is the physician in
particular, and people in general, around which all these principles and
actions revolve and through which they come to fruition. Therefore, in
order to ensure the practice of these principles, it is necessary that morals
and values be ingrained within all individuals in the field of medicine,
ranging from the physician to the custodian. It is a known fact that the
process of moral development begins from early childhood and continues
on through higher education taking place at home and in other institutions.
However, this moral development can only be firmly ingrained through
associating it with God-consciousness and a belief in God and the Day of
19
Ibid.
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Judgment. It is perhaps this negligence of the element of faith, which
started during the Renaissance era, that has resulted in today’s European
and Western reality. In my opinion, this argument is one that is perhaps
embraced by all individuals who believe in God and the Last Day, whether
they are Jewish, Christian, or Muslim or belong to any other religion that
is based on the belief in a person’s accountability to an Omniscient God.
The connection between morality and faith is a central issue in Islam
and is pervasive throughout its creed, worship practices, and rituals, all
of which are intended to affect a person’s actions and behavior. For
example, a person who, believes that God sees him in all situations will
be wary of disobeying God’s commandments or committing any sins. He
believes that God is Omnipotent over His creation. In turn, he holds a
firm conviction that if he commits any injustice, harm, or betrayal
towards another person or practices any other type of wrongdoing and
does not suffer consequences in this world, he will undoubtedly be held
accountable for these actions and will suffer due punishment on the Day
of Judgment. On the other hand, if he obeys God’s orders and maintains
positive conduct, he will be rewarded accordingly and will enter Paradise
in the Hereafter.
As with belief, Islam emphasizes a strong connection between worship practices and their impact on a person’s behavior. For instance, in
regards to prayer, God says, “… Indeed, prayer prohibits immorality and
wrongdoing …” (Qur’an 29:45). In regards to fasting, God says, “O you
who have believed, decreed upon you is fasting as it was decreed upon
those before you that you may attain taqwá” (Qur’an 2:183). Similarly, in
reference to almsgiving (zakāh), God says, “Take, [O, Muhammad], from
their wealth a charity by which you purify them and cause them increase,
and invoke [God’s blessings] upon them. Indeed, your invocations are
reassurance for them. And God is Hearing and Knowing” (Qur’an 9:103).
In other words, it is intended to purify their hearts from greed, selfishness,
and other evils of the heart and simultaneously enable them to rise to
noble character. In fact, prior to prayer, God described good moral
behavior and noble character as a form of worship in His saying, “And
the servants of the Most Merciful are those who walk upon the earth
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Response by Ali Al-Qaradaghi 131
easily, and when the ignorant address them [harshly], they say [words of]
peace” (Qur’an 25:63).
Indeed, all religions founded on the belief in God and the Last Day
have a profound effect on their followers and establish a strong commitment to ethics and moral behavior. This element of faith should not be
neglected, especially within environments characterized with a strong
religious aspect. For those societies that lack this religious element,
morality should be nurtured in accordance with the natural disposition
(fi rah) that all humans are born with.
A final issue that I would like to address is the correlation between the
principles of beneficence and utilitarianism. There has been a great deal
of controversy around this issue by those critics doubting the applicability
of beneficence as a foundation for making ethical decisions. In her paper
“Applying the Four Principles,” Professor R. Macklin describes a study
that was designed to determine the economic and health impacts of selling
a kidney. The study’s participants comprised 305 individuals from
Chennai, India who had sold their kidneys. According to the results of the
study, 96 percent of the participants had sold their kidneys to pay off
debts, and the average price of a kidney was $1,070. Most of the money
received was spent on debts, food, and clothing. The study also revealed
that the effects of undergoing a nephrectomy included a one-third decrease
in the average family income of participants, and 86 percent of participants reported deterioration in their health. Further, 97 percent of the
participants did not recommend for others to sell their kidneys.
Although this is one study that took place in one country, it nonetheless highlights a critical issue that remains contentious to this day. That is,
how can the negative social, economic, and health impacts be balanced
with the benefits received by those who purchase the kidneys?20 Macklin
also referred to another anthropological study that found that the predominant reason behind people selling kidneys was their need to pay off
high interest debts to local moneylenders. In addition, it found that most
20
See Ruth Macklin (2003). Applying the four principles. Journal of Medical Ethics 29(5):
275–280.
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of the money from selling a kidney ended up with organ brokers, while
only a small portion was paid to the sellers themselves.
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References Used for this Response
(1) Some Islamic sources including the Qur’an, books of exegesis, books
of hadith, and books tackling the issue of morality and self-purification
such as: Al-Ghazali, M.: Iyā’ ‘ulūm al-dīn and books of Ibn Al-Qayyim
on ethics and self-purification.
(2) I referred to some books on medicine and medical ethics, such as
books of Dr. Mohammed Al-Bar, Dr. Hassan Hathout, etc.
(3) I made use of websites of medicine and medical ethics and some
translated journals.
(4) I referred to the following books:
(A) Ali Al-Muhammadi and Ali Al-Qaradaghi (2005). Fiqh al-qaḍāyā
al-ibbīyah al-mu‘āirah. Beirut: Dar Al-Basha’ir Al-Islamiyah.
(B) Nahidah Al-Baqsami (1993). Al-handasah al-wirāthīyah wa-alakhlāq, ‘Alam Al-Ma‘rifah series. Kuwait: National Council for
Culture and Art.
(C) David B. Resnik (1998). The Ethics of Science: An Introduction.
London: Routledge.
(D) Zuhayr Al-Karmi (1978). Al-‘ilm wa-mushkilāt al-insān
al-mu‘āir, ‘Alam Al-Ma‘rifah series. Kuwait: National Council
for Culture and Art.
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The Principles of Biomedical
Ethics Revisited
Annelien L. Bredenoord
Abstract: The four-principles approach became widely used in Western
healthcare and academia. However, ever since its introduction, this approach
has also evoked debate. How should the principles be interpreted? Is there
a hierarchy between the four principles? To whom do they apply, i.e. to
whom do we owe these moral obligations and who should be included
within the moral circle? How can concrete action-guides be derived from
the abstract principles? Are the principles indeed universal, as proponents
argue? Are these general principles sufficiently sophisticated to function
as a bioethical theory — pejoratively called “principlism”? In this chapter,
I examine first the premise and challenges of each principle. Subsequently,
I identify three debates regarding principlism as a bioethical theory and
method: (i) whether a pluralist or eclectic approach is an appropriate
one and if so, whether general principles are sufficiently sophisticated
to function as a bioethical theory; (ii) whether there is a hierarchy in
the principles; and (iii) how to arrive at concrete moral judgments from
general ethical principles. I conclude with some future directions for the
four-principles approach.
133
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1. Introduction
Bioethics has become a field of scholarly enquiry in which it is widely
accepted to analyze ethical issues from diverse ethical perspectives, using
arguments derived from several ethical theories including utilitarianism,
deontology, virtue ethics, ethics of care, and contract-based theories. One
of the most prominent among such an eclectic or pluralist approach as
regards ethical theory is the “four-principles approach,” developed in the
1970s by the philosophers Tom Beauchamp and James Childress in their
seminal textbook Principles of Biomedical Ethics. During these years, the
use of a principle-based approach became established in the context of the
United States National Commission for the Protection of Human Subjects
of Biomedical and Behavioral Research, the first committee in the US to
shape bioethics policy and make recommendations for ethical principles
in biomedical and behavioral research involving human research participants. The Belmont Report,1 probably the committee’s most well-known
document, advanced three principles underlying biomedical research
ethics: respect for persons, beneficence, and justice.
Beauchamp (who served as a member of this committee) and
Childress offer a principle-based ethical framework, based on four “prima
facie” moral commitments: respect for autonomy, beneficence, nonmaleficence, and justice. A “prima facie” or “conditional” duty means that a
principle must be fulfilled unless it conflicts with an equal or stronger
principle. The approach, however, does not provide a method for choosing,
meaning there is no “algorithm” to prioritize a principle and derive the
moral answer.2 Unlike the Belmont Report, Beauchamp and Childress did
not select three but four ethical principles, hence, “the four-principles
approach.” The principles are ranked below ethical theories but above
particular rules.3 Although these principles do not provide action guides
1
The National Commission for the Protection of Human Subjects of Biomedical and
Behavioral Research (1979). The Belmont Report: Ethical Principles and Guidelines for
Protection of Human Subjects of Biomedical and Behavioral Research. Available online via
http://www.hhs.gov/ohrp/humansubjects/guidance/belmont.html (retrieved 15 February 2016).
2
Raanan Gillon R. (1994). Medical ethics: Four principles attention to scope. British
Medical Journal 309:184.
3
K. D. Clouser and B. Gert (1990). A critique of principlism. Journal of Medicine and
Philosophy 15: 219–236.
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The Principles of Biomedical Ethics Revisited 135
and need derivative rules and specification in concrete cases, they aim to
help physicians and other healthcare workers make moral decisions in
medical practice.4 They aim to provide a common moral language, compatible with most intellectual, cultural and religious beliefs. This universal
claim of the four-principles approach may fit in an intercultural bioethical
dialogue that avoids ethical relativism. In that sense, they can be defined
as a variant of the Rawlsian “overlapping consensus”: essentials we
should all agree upon in order to make a society possible.5
The four-principles approach became widely used in Western healthcare and academia. However, ever since its introduction, this approach has
also evoked debate. How should the principles be interpreted? Is there a
hierarchy between the four principles? To whom do they apply, i.e. to
whom do we owe these moral obligations and who should be included
within the moral circle? How can concrete action-guides be derived from
the abstract principles? Are the principles indeed universal, as proponents
argue? Are these general principles sufficiently sophisticated to function
as a bioethical theory — pejoratively called “principlism”?
In this chapter, I will closely examine the four-principles approach.
The premise and challenges of each principle will first be discussed.
Subsequently, I will identify three debates regarding principlism as a
bioethical theory and method: (i) whether a pluralist or eclectic approach
is an appropriate one and if so; whether general principles are sufficiently
sophisticated to function as a bioethical theory; (ii) whether there is a
hierarchy in the principles; and (iii) how to arrive at concrete moral judgments from general ethical principles. I will conclude with some future
directions for the four-principles approach.
2. The Four Principles: General Overview
2.1. Respect for Autonomy
The term “autonomy” originally stems from the self-governance of the
independent Greek city-states and has subsequently been extended to
individuals. There are different understandings of and justifications for
4
5
Gillon (1994), op. cit.
John Rawls (1993). Political Liberalism. New York: Columbia University Press.
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the concept of autonomy, but individual (or personal) autonomy is
generally understood to refer to the capacity to be one’s own person, to
live one’s life according to reasons and motives that are taken as one’s
own and not the product of manipulative or distorting external forces.6
Two developments underlie the rise of the principle of respect for autonomy in bioethics in the 1960s: the rapid developments in biomedical
technologies and a growing concern about the power exercised by physicians and researchers. Autonomy became a central value in Western (bio)
ethics, mainly supported by deontological and utilitarian ethical theories.
I consider the principle of respect for autonomy to be significant for
various reasons. First, in a pluralistic world, where people have different
conceptions of the good life, the presumption should be that people are
given the liberty to make their own decisions and live according to their
values and beliefs, or in other words, that people are granted the liberty to
act in accordance with their autonomy.7 This is even more important when
it concerns personal and identity determining decisions, which is often the
case in healthcare. Second, human flourishing is constituted to a considerable extent in the exercise of one’s autonomy.8 After all, a person may
flourish and lead a good life when she is able to formulate and pursue
human ends.9 In healthcare, the principle of respect for autonomy has
many implications. The most well-known duty derived from autonomy is
the requirement to obtain informed consent (or informed refusal), which
can be defined as the autonomous authorization (or refusal) from a patient
or research participant for a specific intervention.10 Medical confidentiality
and privacy are other implications of respecting people’s autonomy.11
6
J. Christman (2011). Autonomy in moral and political philosophy, in Edward N. Zalta
(ed.), The Stanford Encyclopedia of Philosophy. Available online via http://plato.stanford.
edu/archives/spr2011/entries/autonomy-moral/ (retrieved 15 February 2016).
7
J. Coggon and J. Miola (2011). Autonomy, liberty, and medical decision-making. The
Cambridge Law Journal 70(3): 523–547.
8
R. Gillon (1985). Autonomy and the principle of respect for autonomy. British Medical
Journal 290: 1806–1808.
9
P. Gardiner (2003). A virtue ethics approach to moral dilemmas in medicine. Journal of
Medical Ethics 29(5): 297–302.
10
J. W. Berg, P. S. Appelbaum, C. W. Lidz and L. S. Parker (2001). Informed Consent.
Oxford: Oxford University Press, 2nd edition.
11
Gillon (1994), op. cit.
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The Principles of Biomedical Ethics Revisited 137
Despite its significance, the precise meaning and interpretation of
autonomy has been the subject of ongoing discussion. Consequently, the
principle of respect for autonomy also became a widely contested and
debated concept — probably the most contested principle in the fourprinciples approach.
One of the main criticisms in regards to the principle of respect for
autonomy has been that the emphasis on autonomy is superficial and eventually degenerates into indifference and a right to rot. Communitarian,12
feminist, and care ethics approaches,13 in particular, have specifically criticized the principle of respect for autonomy for being too individualistic,
emphasizing that autonomy cannot exist independent of relationships. I
think this criticism is partly due to a mistaken and excessively one-dimensional interpretation of the concept. It is important to make a distinction
between the negative and the positive aspects of autonomy.14 Autonomy in
its negative (or thin) sense means the right to make one’s own decisions
without interference or coercion from others. It is “freedom from” and
closely associated with the political concept of “liberty” — and sometimes
even equaled with the concept of liberty.15 This account of autonomy is a
necessary though insufficient condition for human freedom. Autonomy in
its positive sense entails the ability to take control over one’s life and to live
according to one’s values and beliefs. It is more closely associated with
concepts such as authenticity, self-expression, and self-governance. Since
not everyone will have the same abilities and opportunities to make one’s
own autonomous decisions and “to be one’s own person,” we sometimes
need others to facilitate and foster our autonomy.16 People often face several difficulties with unrestricted decision making and in fully exercising
their autonomy. These difficulties may comprise internal and external
impediments for autonomous decision making, e.g. people’s inability to
12
D. Callahan (2003). Principlism and communitarianism. Journal of Medical Ethics 29:
287–291.
13
C. MacKenzie and N. Stoljar (eds.) (2000). Relational Autonomy: Feminist Perspectives
on Autonomy, Agency, and the Social Self. Oxford: Oxford University Press.
14
I. Berlin (1969). Four Essays on Liberty. Oxford: Oxford University Press.
15
Coggon and Miola (2011), op. cit.
16
J. Feinberg (1987). Harm to Self. The Moral Limits of the Criminal Law, Vol. 3. Oxford:
Oxford University Press.
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comprehend the information provided, individual difficulties with making
complex decisions, people’s ambiguity regarding their own values and
preferences, a lack of realistic alternatives, the psychological and emotional
pressures of making a decision, etc. This is, for example, shown when
patients face difficult decisions when undergoing next generation DNA
sequencing. The quantity, significance and ambiguity of genetic findings
will make any reasonable choice beforehand highly complex.17 Autonomy
is a gradual concept, an ideal, not an absolute reality. As Feinberg18 has put
it: it is an ideal that should be facilitated and fostered. Therefore, I embrace
a much more substantial, thick interpretation of autonomy, where both the
negative and positive aspects are acknowledged.
A second, related point of discussion concerns the scope of the principle of respect for autonomy. Some individuals are temporarily or permanently considered non-autonomous agents, such as children, the mentally
ill, individuals in a permanent vegetative state, comatose individuals, or
unconscious individuals. However, there are many shades of grey in this
regard. Whereas an unconscious person would not be able to exercise her
autonomy, there are many young children and mentally disabled individuals
who may be able to make some decisions and express some preferences.
Their decision-making capacity fluctuates. It is therefore important to
realize that the capacity for autonomy is a gradual concept. Even though
children, for example, are not yet able to fully exercise their autonomy,
showing respect for children’s future autonomy can still be warranted by
postponing decisions that unnecessarily restrict their future options in
life.19 In addition, their current rights can be respected by obtaining their
assent and engaging them in the decision-making process.20 Similarly,
17
A. L. Bredenoord, N. C. Onland-Moret and J.J. M. Van Delden (2011). Feedback of
individual genetic results to research participants: In favour of a qualified disclosure policy. Human Mutation 32: 861–867; A. L. Bredenoord, R. Bijlsma, J. J. M. Van Delden
(2015). Next generation DNA sequencing: Always allow an opt out. American Journal of
Bioethics 15(7): 28–30.
18
Ibid.
19
A. L. Bredenoord, M. C. De Vries and J. J. M. Van Delden (2013). Next generation
sequencing: Does the next generation still have a right to an open future? Nature Reviews
Genetics 14: 306 doi:10.1038/nrg3459.
20
N. A. A. Giesbertz, A. L. Bredenoord, and J. J. M. Van Delden (2014). Clarifying assent
in pediatric research. European Journal of Human Genetics 22(2): 266–229.
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The Principles of Biomedical Ethics Revisited 139
psychiatric patients with reduced decision-making capacity can still be
involved by means of supportive measures.21
A third criticism of the principle of respect for autonomy concerns
placing excessive emphasis on the centrality of autonomy, leaving little
room for competing societal interests. Indeed, at the macro level, the
major shortcoming of autonomy is what Hardin22 coined the “Tragedy of
the Commons.” This is the dilemma arising from a lack of coordination
among individuals who rely on a shared resource, resulting in the situation in which multiple individuals, acting independently and rationally
consulting their own self-interest, will ultimately deplete a shared, limited resource (or shared values) even when it is clear that it is not in
anyone’s long-term interest for this to happen. For example, all individual, well-informed decisions to abort female fetuses may in the end have
a negative net effect on society at large, or all individual decisions to opt
out of bio-banking research will ultimately result in impediments in
research and healthcare. Actually, respect for autonomy is the moral obligation to respect the autonomy of others “in so far as such respect is
compatible with equal respect for the autonomy of all potentially
affected.”23 This implies that autonomy “is an important moral limit but
also limited.”24
Just as Beauchamp and Childress have never defended an unfettered,
unrestricted place for individual autonomy, I would embrace a much more
substantial, thick interpretation of autonomy, where both the negative and
positive interpretations are acknowledged. Such a thick account of autonomy is more relational, more in line with human shortcomings, more
sensitive to competing societal interests and less prone to the alleged
“right to rot” criticism. This view can be positioned in current liberal
thinking that can be described as “social liberalism” (or “progressive liberalism”), as opposed to the classical or neo-liberal point of view. Classical
21
F. H. Van der Baan, R. Bernabe, A. L. Bredenoord, J. G. Gregoor, G. Meynen and
G. J. M. W. van Thiel (2012). Consent in psychiatric biobanks for pharmacogenetic
research. International Journal of Neuropsychopharmacology 21:1–6.
22
G. Hardin (1968). The tragedy of the commons. Science 162: 1243–1248.
23
Gillon (1994), op. cit.
24
J. F. Childress (1990). The place of autonomy in bioethics. Hasting Center Report
20(1): 12–17.
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and social liberalism differ in their view on mankind, in their interpretation of liberty and autonomy, and in the role they see for the state.25
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2.2. Nonmaleficence and Beneficence
Whereas the principles of autonomy and justice were only introduced in
bioethics in the 1960s, the principles of nonmaleficence and beneficence
stem from the old Hippocratic tradition in medical ethics. These two
principles are the classical “physician” principles, directed at the doctor–
patient relationship (contrary to the “novel” principles of autonomy and
justice that focus on the individual and society).
The principle of nonmaleficence, or “first, do not harm,” requires the
avoidance, whenever possible, of causing harm to others. Harm is defined
as a setting back of the interests of an individual.26 Among the four principles, nonmaleficence probably is the least contested principle — as far
as we are aware, no authors have criticized this obligation not to harm
patients and research participants. One possible criticism could be that the
demarcation between nonmaleficence and beneficence is difficult to draw,
particularly when, for example, the withholding of a proven beneficial
treatment is included in the principle of nonmaleficence. Although withholding a treatment is an omission rather than an action, it represents a
decision and could therefore be perceived as an action.27 This same action,
however, could arguably also be allocated to the principle of beneficence.
The principle of beneficence is, in fact, a group of principles. It requires
three elements: that we prevent harm from occurring, that we remove
harmful conditions that exist, and that we promote the good of the other.28
I identify three challenges with this principle.
First, if used without restrictions and if not balanced with other principles, it may lead to paternalism, as the physician may use this principle
as a justification to endlessly intervene for the sake of the patient. Hence,
25
A. Van Witteloostuijn, M. Sanders, D. Hessling and C. Hendriks (2012). Governing
Governance. A Liberal–Democratic View on Governance by Relationships, Bureaucracies
and Markets in the 21st Century. Brussels: European Liberal Forum.
26
T. L. Beauchamp and J. F. Childress (2013). Principles of Biomedical Ethics. New York/
Oxford: Oxford University Press, 7th edn.
27
R.Macklin (2003). Applying the Four Principles. Journal of Medical Ethics 29: 275–280.
28
Beauchamp and Childress (2013), op. cit.
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The Principles of Biomedical Ethics Revisited 141
one must continuously be aware of the thin line between justified and
unjustified paternalism. Moreover, we sometimes need to ask individuals
what is in their best interest, which is the reason that autonomy is a natural
counterpart to this principle.
Second, there is debate regarding the scope and limits of beneficence.
Beneficence is a maximizing principle. If taken without restrictions, how
much effort could be asked and should be exerted in promoting the interests
of others? Here one arrives at the so-called demandingness debate, a debate
in philosophy that discusses what individuals may reasonably ask of each
other. The physicians’ and researchers’ protective duties are generally clear
and strong. However, physicians’ and researchers’ duties to promote the
best interests of others need more elucidation. The principle of beneficence
therefore requires clear demarcations that take into consideration issues
such as proportionality, feasibility, and the principle of autonomy.
Finally, some have argued that beneficence, understood as the moral
ideal of helping each other, should not be considered a duty, as it is not
morally required but rather an ideal that is praiseworthy or even supererogatory and heroic.29
2.3. Justice
The principle of justice also concerns a group of principles requiring fair
distribution of benefits, risks, and costs across all parties in a society.
Justice regulates cooperation. However, this principle alone is rather “hollow” and must be supplemented by a theory of justice. Twentieth century
political philosophy has exerted considerable efforts to do so.
Equality is regarded by many as being at the heart of justice. Justice,
however, is more than mere equality, given that people may be treated
unjustly even if they are treated equally,30 and not all inequalities are necessarily injustices.31 Moreover, to treat everyone equally is purely impossible. A refinement could therefore be made in that equals receive equal
treatment (horizontal equity) while unequals receive unequal treatment in
proportion to their morally relevant inequalities (vertical equity).32
29
Clouser and Gert (1990), op. cit.
Gillon (1994), op. cit.
31
M. Powers and R. Faden (2006). Social Justice. Oxford: Oxford University Press.
32
Gillon (1994), op. cit.
30
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Needless to say, what the phrase “morally relevant inequalities” exactly
entails has been the subject of ongoing debate.
A distinction can be made between formal theories of justice and
material theories of justice. A formal (also known as procedural) theory
of justice defines the procedure for treating each other fairly, usually in
reference to the condition espoused by Aristotle: equals must be treated
equally, and unequals must be treated unequally. More recent examples
constitute theories in “fair process” (or accountability for reasonableness),
where the outcomes of fair procedures should count as fair when we cannot
agree on more substantive principles for resolving disputes on justice and
when specific conditions in such a procedure are satisfied, e.g. that decision-makers are accountable for the reasonableness of their decisions.33
Such a theory is formal because it identifies no particular respects in which
equals should be treated equally and provides no criteria for determining
whether two or more individuals are in fact equal. Such a formal principle
lacks substance and, in turn, fails to provide a criterion with which to differentiate between individuals. Who is equal and who is unequal? When is
differentiation permitted? Which inequalities matter most?34 For example,
if there is a job vacancy, candidates will differ in gender, race, merit,
capacities, age, and skills. What basis for differentiation is justified and
what is not? Similarly, in situations where organs are limited (e.g. kidneys)
and there are several suffering individuals on a waiting list, how can we
make a justifiable distinction and whom should be included in the moral
circle — are there people to whom we owe more by virtue of special relationships, proximity, or roles? Further, should we include only those who
suffer from organ failure due to external circumstances or also include
those who became ill due to their own unhealthy behavior?
To answer these questions, one needs a material principle of justice.
Traditional (material) theories of justice include utilitarian theories, libertarian theories, egalitarian theories, and communitarian theories in addition
to more recent theories of justice which include the capability approach as
well as several other well-being theories. Each theory of justice formulates
some relevant property on the basis of which burdens and benefits should
33
34
N. Daniels (2008). Just Health. Cambridge: Cambridge University Press.
Powers and Faden (2006), op. cit.
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The Principles of Biomedical Ethics Revisited 143
be distributed, e.g. (i) to each person an equal share, (ii) to each person
according to individual need, (iii) to each person according to individual
effort, (iv) to each person according to societal contribution, and (v) to
each person according to merit.35 Clearly, the principle of justice is only a
starting point, but it is a “hollow” concept as such. The real moral work is
in choosing and justifying a theory of justice and subsequently arguing for
what constitutes morally justified discrimination.
3. Principlism as a Method in Bioethics
Broadly speaking, three (strongly related) debates regarding principlism as
a bioethical theory and method can be identified: first, whether a pluralist
or eclectic approach is an appropriate one and if so, whether general principles are sufficiently sophisticated to function as a bioethical theory; second, whether there is a hierarchy in the principles; and third, how to arrive
from general ethical principles to concrete moral judgments.
3.1. Pluralism or Monism
A first topic of ongoing debate has been whether a pluralist or eclectic
approach is an appropriate one in bioethics and if so, whether general
principles are sufficiently sophisticated to function as a bioethical theory.
The general, content-thin character of the four principles has been considered as both an asset and a drawback. It has been applauded for its clarity
and simplicity, for being a straightforward method of general (perhaps
even universal) principles. Many perceive it as a great educational tool
and an attractive and applicable framework for the analysis of everyday
bioethical issues. It has particularly been mentioned as a useful checklist
approach for clinicians, non-philosophers, and those new to the field.36
The four-principles approach, on the other hand, has also been criticized for being simplistic, a kind of ethical reductionism that would
35
Belmont Report (1979), op. cit.
Gardiner (2003), op. cit.; R. Gillon (2003). Ethics needs principles — four can encompass the rest — and respect for autonomy should be “first among equals”. Journal of
Medical Ethics 29: 307–312; J. Harris (2003). In praise of unprincipled ethics. Journal of
Medical Ethics 29: 303–306.
36
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ignore the complexity of life and the ambiguity of ethical dilemmas.
It would lead to sterility and uniformity of approach.37 Moreover, some
have more profoundly argued that any principlist approach misconceives
both ethical theory and practice, for principles neither function as adequate
surrogates for moral theories nor as directives or guides for determining
the morally right action.38 Whereas in classical ethical theories the leading
principle embodies the ethical theory, principlism offers several often
competing principles, without offering a method for choosing and balancing these principles. Principlism would provide a number of conflicting
principles and then tell one “to pick whatever combination we like.”39
Since there is no single moral theory that ties the four principles together,
it has been criticized for having no action guide that generates clear and
coherent rules for action or justifications for those rules.40
This kind of criticism touches on underlying epistemological debates in
ethics, with differing conceptions of what moral theory is or should be.41
Whereas foundationalists expect an ethical theory to be well-developed and
a clear directive for the morally right action, principlists are less demanding
as regards ethical theory and are more willing to accept a loose framework
for normative deliberation.42 Beauchamp and Childress clearly adopt the
latter position when they admit that ethics thus far did not find principles
that are self-evident or self-justifying: there is an infinite regress, “a neverending demand for final justification — because each level of appeal to a
covering precept requires further general level to justify that precept.”43
Should the ethicist commit herself to one ethical theory, or is a pluralist
or eclectic approach acceptable? I think good reasons exist to steer a middle course here. Whereas it may not be possible and desirable to remain
completely neutral with regards to ethical theory, much is to be said for
pluralism as a general approach, especially in applied ethics. After all,
37
Callahan (2003), op. cit.; Harris (2003), op. cit.
Clouser and Gert (1990), op. cit.
39
Ibid.
40
Ibid.
41
R. B. Davis (1995). The principlism debate: A critical overview. Journal of Medical and
Philosophy 20: 85–105.
42
Ibid.
43
Beauchamp and Childress (2013), op. cit., 393.
38
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The Principles of Biomedical Ethics Revisited 145
those dedicated to one particular ethical theory will only convince people
who believe in the truth of this ethical theory. In addition, one can doubt
the prospect of success of using one single ethical theory to tackle the
complex ethical quandaries in modern medicine and life sciences.
Moreover, a suitable model to integrate principles, intuitions, morally
relevant facts, and different relevant background theories into a coherent
moral view is available: “wide reflective equilibrium” (RE).44 The general
idea behind RE is that dealing with moral questions requires an argumentative process of seeking equilibrium between beliefs stemming from
practice (morally relevant facts and moral intuitions) and those stemming
from theory (principles and background theory). The term RE is used for
both the process and the result of moral reasoning.45 This reasoning process in RE can be characterized as “going back and forth” between beliefs
stemming from practice and from theory.46 From the perspective of RE,
ethical reasoning is analogous to methods in science: in a continuous process we test hypotheses, modify them, and refine them or reject them
through experiments and experimental thinking.47 In the ethical analysis,
the applied ethicists can use a variety of theories and arguments stemming
from various ethical approaches and various disciplines, including methods
stemming from the social sciences. RE is therefore particularly suitable
as a method for the “empirical turn” in bioethics, where bioethics
accommodates empirical research in her analysis.48 Such a pluralist
approach that makes use of RE asks special skills from the ethicist: she
should on the one hand be sufficiently “embedded” so as to have knowledge of the relevant facts, considerations, and theories, but she should on
44
J. Rawls (1971). A Theory of Justice, revised edn. Cambridge: The Belknap Press of
Harvard University Press.
45
G. J. M. W. Van Thiel and J. J. M. Van Delden (2008). The justificatory power of moral
experience. Journal of Medical Ethics 35: 234–237.
46
J. J. M. van Delden and G. van Thiel (1998). Reflective equilibrium as a normative
empirical model in bioethics, in W. Van Der Burg and T. van Willigenburg (eds.).
Reflective Equilibrium. Deventer, Kluwer: 251–259; Rawls (1971), op. cit.; W. Van der
Burg and T. van Willigenburg (1998). Introduction, in W. Van Der Burg and T. van
Willigenburg (eds.). Reflective Equilibrium. Deventer: Kluwer: 1–25.
47
Beauchamp and Childress (2013), op. cit.
48
P. Borry, P. Schotsmans, and C. Dierickx (2005). The birth of the empirical turn in
bioethics. Bioethics 19(1): 49–71.
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the other hand be sufficiently remote so as to make a critical, ethical
assessment. The ultimate aim in bioethics is to reach moral justification,
or, in other words, to establish one’s case by presenting sufficient and
coherent grounds for it, which does not necessarily imply that these
grounds should be derived from one single ethical theory. When and under
what conditions moral justification is reached (and the limitations therein)
is discussed below.
3.2. Hierarchy
Ever since the principles were introduced, a second point of debate has
revolved around how the principles (should) relate to each other,49
whether there is a hierarchy in the principles, and whether autonomy
would (and should) be given priority. As Davis50 has highlighted, it is not
entirely clear how the four principles systematically relate to one
another. Moreover, it is unclear whether they should require systematic
relation — Beauchamp and Childress seem to adopt the position that this
should not necessarily be the case.51 In addition, the theorists behind the
four-principles approach did not prioritize any particular principle. They
have repeatedly emphasized that no single principle overrides all other
moral considerations: “it is a mistake in biomedical ethics to assign priority to any basic principle over other basic principles — as if morality
must be hierarchically structured or as if we must cherish one moral
norm over another without consideration of particular circumstances.”52
This position has been challenged from two directions: some have
argued that principlism should prioritize a principle and more specifically
that autonomy should be “first among equals,”53 and others have argued
that principlism perhaps not in theory but at least in practice prioritizes
autonomy. As one commentator put it: it became “a kind of one note
theory with a few underlying supportive melodies.”54
49
Davis (1995), op. cit.
Ibid.
51
Ibid.; Beauchamp and Childress (2013), op. cit.
52
Beauchamp and Childress (2013), op. cit., ix.
53
Gillon (2003), op. cit.
54
Callahan (2003), op. cit., 289.
50
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The Principles of Biomedical Ethics Revisited 147
I think some good reasons exist to assign a special place to the
principle of respect for autonomy, but in that case only autonomy as
described above: in a thick account. First, respect for autonomy is the only
principle that directly relates to and limits the other three principles; it is
the “alpha and omega” of any principle-based approach. For example, to
not harm another person, i.e. nonmaleficence, is also to show respect for
that person’s autonomy. In addition, autonomy forms the natural counterpart of beneficence in order to avoid acting “in the sake of the patient, but
without the patient.” Even an obviously beneficial treatment can be
refused — provided the patient is competent. Promoting someone’s
interest also requires us to know what constitutes one’s interests, which
leads to the requirement to obtain informed consent (or refusal) if possible. Finally, respect for people’s autonomy must be an integral component
of any conception of justice, albeit formal or material theories. Combined
with the ethical, religious, and cultural pluralism of modern societies,
respect for autonomy can be considered a core concept. Political liberalism assumes that a plurality of reasonable but often incompatible comprehensive doctrines is an essential characteristic of modern democratic
regimes.55 In such a pluralist world, where people have different conceptions of the good life, the presumption should be that a person’s autonomy
is at least respected and where possible also promoted — with all the
caveats and restrictions mentioned above.
3.3. Specification
A third topic of ongoing debate is how to arrive from general ethical principles to concrete moral judgments. As discussed above, the general,
content-thin character of the four principles has been considered as both
an asset and a drawback. Principlism has been attacked for being on the
one hand a much too rigid system that would deductively lead to simplistic moral solutions for complex ethical dilemmas and on the other hand
for not providing sufficient tools to arrive at concrete moral judgments.56
Indeed, general principles require further interpretation and application to
55
56
Rawls (1993), op. cit.
Macklin (2003), op. cit.
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real-world bioethical problems. To have genuine impact and relevance,
bioethics should not only seek to locate the realm of moral issues but also
to decide on them.57 How do general principles relate to particular moral
judgments in concrete situations?
Moral problems need conceptual and normative clarification with
adequate knowledge of the medical facts, as the particulars of a specific
case may give general considerations a special salience. Whereas general
principles are content thin, particular moral judgments are content rich.58
Three ways to bridge principles to concrete, particular judgments can be
identified.59
(i) Application: the right course of action is deduced from general
principles and rules.
(ii) Balancing: conflicting principles are weighed in order to determine
which has priority in the specific situation.
(iii) Specification: the process of qualitatively tailoring our norms to
cases by spelling out where, when, why, how, by what means, to
whom, or by whom the action is to be done or avoided.
Beauchamp and Childress are committed mostly to the process of
specification, defined as “a process of reducing the indeterminateness of
general norms to give them increased action guiding capacity, while
retaining the moral commitments in the original norm.”60 However, problems may lurk when applying principles to specific cases.61 The challenge of specification has been illustrated by Toulmin when he wrote
about his experience as a member (1975–1978) of the United States
National Commission for the Protection of Human Subjects of Biomedical
57
S. Toulmin (1982). How medicine saved the life of ethics. Perspectives in Biology and
Medicine 25: 736–750.
58
T. L. Beauchamp (2003). Methods and principles in biomedical ethics. Journal of
Medical Ethics 29: 269–274.
59
H. Richardson (1990). Specifying norms as a way to resolve concrete ethical problems.
Philosophy and Public Affairs 19: 279–320; J. F. Childress (2001). A principle-based
approach. In H. Kuhse and P. Singer (eds.). A Companion to Bioethics. Blackwell
Companions to Philosophy: 61–79.
60
Beauchamp (2003), op. cit.
61
Macklin (2003), op. cit.
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The Principles of Biomedical Ethics Revisited 149
and Behavioral Research: “I was struck to the extent by which the
commissioners were able to reach agreement in making recommendations about ethical issues of great complexity and delicacy. If the earlier
theorists had been right, and ethical considerations really depended on
variable cultural attitudes or labile personal feelings, one would have
expected 11 people of such different backgrounds as the members of the
commission to be far more divided over such moral questions than they
ever proved to be in actual fact (….) The problems that had to be argued
through at length arose, not on the level of the principles themselves, but
at the point of applying them.”62 Whereas very general moral principles
could be embraced by all persons, specified moral judgments are “works
in progress” or “provisional fixed points” that can legitimately vary
between persons and that require continuous refinement and adjustment
when relevant data would give cause to do so.63
When is a specified moral judgment justified? Beauchamp considers
a specification justified if it is (a) consistent with (does not violate) the
norms of common morality and (b) internally coherent with the overall set
of relevant, justified beliefs of the party doing the specification.64
Although RE is a suitable model to integrate principles, intuitions, morally relevant facts, and different relevant background theories into a
coherent moral view, no accepted account on what constitutes common
morality thus far exists. Gert65 has defined common morality as the moral
system that most thoughtful people implicitly use in arriving at moral
judgments. Anyone who accepts common morality makes a universal,
anti-relativist claim that a morality exists that is compatible with most
intellectual, cultural, and religious beliefs. The challenge of course is finding and defining this morality and formulating it in such a language that
it can be accepted by people from diverse intellectual, cultural, religious,
and professional backgrounds. Beauchamp and Childress “did not attempt
to construct a comprehensive theory of the common morality,”66 but they
62
Toulmin (1982), op. cit., xx.
Beauchamp (2003), op. cit.; Rawls (1971), op. cit.
64
Beauchamp (2013), op. cit.
65
Bernard Gert (2004). Common Morality: Deciding What to Do. Oxford: Oxford
University Press.
66
Beauchamp and Childress (2013), op. cit., 396.
63
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do claim that the four principles are drawn from the common morality.
Whether the four principles will be broadly accepted outside the Western
world, by people for example in Islamic, Buddhist, Confucian, and other
traditions is not only a theoretical or normative question, but also an
empirical one — which would be an interesting field to further explore
empirically. An important theoretical issue for future research is to systematically develop an account on common morality and to elaborate on
how the principles are positioned in the common morality.
3.4. Future directions
In many Western hospitals and universities, (medical) students are taught
the four principles of bioethics. Principlism became influential and
widely used, but also vigorously debated. Both the content of the principles and the strengths and weaknesses of principlism as a bioethical theory and method have been topics of ongoing discussion. I consider the
four-principles approach an attractive and applicable framework for an
in-depth analysis of ethical dilemmas in biomedicine as well as a great
educational tool to help physicians and other healthcare workers to make
moral decisions in medical practice. Due to the general, content-thin
character of the principles, principlism may have a wide appeal amongst
different professions, cultures, and nationalities and thereby provide a
common moral language. However, this also means that the translation of
abstract ethical principles in concrete moral judgments requires an elaborate and continuous scholarly process of fine-tuning and extensive argument. The quality of a specification, therefore, shows “the art and
experience of the ethicist.”
Just as science and ethics are works in progress, resulting in provisional fixed points that require continuous refinement and adjustment, so
also does the four-principles approach require continuous maintenance. At
least two themes should be on the agenda for future research. First, I think
a pluralist approach is an appropriate one, particularly in bioethics.
Although I follow Beauchamp and Childress in their position that there is
no hierarchy in the principles (if there were a hierarchy, one endorses
monism instead of pluralism), at the same time some good reasons exist
to assign a special place to the principle of respect for autonomy — based
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The Principles of Biomedical Ethics Revisited 151
on the thick account, where both the negative and positive interpretations
are acknowledged. How the principles should be positioned towards each
other and how the (thick account of the) principle of autonomy fits in is
an important topic for further research. Second, the four-principles
approach leans heavily on the existence of a common morality. Another
important theoretical issue for future research is therefore to systematically develop an account on common morality and to elaborate on how the
principles are positioned in the common morality. This is of special
importance for the purpose of this book, aimed at exploring whether universal principles in bioethics do exist. Just as “medicine saved the life of
ethics,”67 contemporary bioethics could be a fruitful avenue for initiating
an intercultural, bioethical dialogue that avoids ethical relativism.
67
Toulmin (1982), op. cit.
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May 2, 2013
14:6
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Script of Oral Discussions
(Day 1, Session 3)
Mohammed Ghaly
In our discussions we will be focusing on two main questions:
(i) What are the Islamic principles in bioethics?
(ii) Are the four principles of bioethics, as defined in the West, universal?
Currently in the field of medical ethics, there is not just a theory or
two, but rather a vast domain of science and research related to the establishment of universal principles of medical ethics. We have two wellrenowned scholars from the West who wrote and published in this field
and whose books are considered the most important resources on biomedical ethics. One of them joins us during the seminar. They defined
the four principles and their theory has not only impacted the Western
world but has also expanded into the Muslim world. For example, Dr.
Al-Bar is busy now writing a book in which he discusses the four principles. What we are hoping to achieve through our discussions is to
review these principles from an Islamic perspective and ask questions
such as, are these four principles compatible with Islam, its heritage, and
its legacy? Are there any adjustments, additions, or deletions that need
to be made? We are also asking the central question of whether these
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ethics are associated with general morals. If so, how can these morals be
determined, and more specifically, which of them pertain to the field of
medicine?
After Tom Beauchamp presented his paper and Ali Al-Qaradaghi
presented his response paper, the following discussion took place.
Tariq Ramadan
After reading your book and listening to your comments today,
Dr. Beauchamp, I have three questions. My first question, especially after
our discussion earlier about ethics, medical sciences, and biomedicine, is:
Why did you have to come up with these four principles? In fact, why do
we need such principles when it comes to ethics? The perception we have
while reading and contemplating what you call “common morality” is that
we need more ethics because there is less religion. So, do we need to rely
on common rationality because we do not have a common reference in
terms of religion? Is this the rationale?
The second question that was raised earlier, by Sheikh Raissouni, is:
How are these four principles (autonomy, nonmaleficence, beneficence,
and justice) specific to medicine or bioethics? For instance, justice could
be used as a principle for everything. Nonmaleficence could also be
applied to everything. So it is wide, and at the end, what are the specificities that we have with these four principles when it comes to bioethics?
The last question, arising from Sheikh Al-Qaradaghi’s last comments,
is: How can we be sure when depending only on rationality and common
morality that at the end, when we have two contradicting values or ethics,
we will not follow the utilitarian process? How can we be sure that we
have in fact a method through which we can decide between two conflicting values based on an ethical choice rather than a utilitarian choice within
the society?
Tom Beauchamp
One question was: Why did we come to the four principles, and the
question was also about the comprehensiveness of the principles. Let me
go back and make a distinction that I take to be very important. First of
all, we came to these four principles in particular and not many other
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Script of Oral Discussions (Day 1, Session 3) 155
principles that we could have discussed because we wanted an adequate
set of principles for biomedical ethics, in a circumstance in which we
simply did not have an adequate set of principles. One might say that
this religion or that culture or whatever did have an adequate set of principles. However, what we wanted is an adequate set of principles so that
all people can talk to all other people. That is to say, one that was universal in character. A part of the question, I believe, has to do with the
role of religion. There was a statement that I was not sure I quite understood. It was something to the effect that you need more ethics because
of less religion or something of that sort. That is not a view that we take.
We think it is simply very critical to have a common morality. You do
not get a common morality out of having many different religions,
which is the de facto situation we have in the world today. We have
many different religious faiths with many different kinds of commitments. So, in order for us to talk to one another, we need a common
morality that has the values that are shared by all of these religious traditions. I might add, for those of you who do not know, that both my
coauthor James Childress, who is a Protestant theologian of the Quaker
faith, and I have graduate educations in theology, and we of course have
the utmost respect for theological approaches. What we want to say is
that the theological approaches in particular traditions will not give you
universal principles. What they give you, precisely, is a particular religious tradition.
Another question was concerning what is specific to biomedical ethics. Quite simply, everything in our book is specific to biomedical ethics
and not specific to something else. For example, it is not a book of general
ethics, and it is not a book about business ethics. It is a book about biomedical ethics. I believe that is the simple answer.
I missed the point about contradictory values and not following utilitarian choices. I am not sure I entirely understand this question, but let me
reconstruct it a bit. In modern society, particularly the way national governments work, it is very easy to fall into a kind of utilitarian way of
thinking. That is to say, you simply balance risks and benefits across
society and you make a decision based purely on what maximizes values.
That is a utilitarian position that is easy to fall into. However, there is no
reason to think that you have to fall into that. In fact, a great deal of what
Childress and I are doing is trying to give you many kinds of options and
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alternatives precisely so that this does not happen. This is my general
answer to what I understand to be the line of questions.
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Mohammed Ghaly
Dr. Ramadan asked a question about the reason you chose these four
principles and not other principles. He also asked about the methodology
you adopted in selecting these four principles only and exclusively.
Tom Beauchamp
The idea is to have all the principles that you need to begin the process of
specification to more specific rules. That does not mean that you have all of
the values that you need. For example, as I said in my talk, we have a
lengthy discussion about virtues. I do not think we can get all virtues out of
these four principles. Simply saying that you have four principles that are
orienting and guiding parts of your system does not mean that it governs all
the values. Clearly, in fact, it does not. For example, I mentioned the moral
ideals. Moral ideals do not conform perfectly to the four principles.
You might ask, what then do the four principles give you? They give
you a coherent, reasonably approachable structure — in other words,
everybody can approach it — body of principles that can be put to work
in biomedical ethics to construct much more specific rules, policies, and
the like. That is the reason.
One additional principle that some people have tried to advance is the
principle of community. If it turns out that we need a principle of community because our account of justice and beneficence does not cover this
aspect adequately, then we would have to add a principle of community.
I am unconvinced, however, based on many discussions over this year that
we need to add or subtract anything.
Mohammed Ghaly
Sheikh Raissouni is asking a question about the fact that the four principles are not specific to medicine and medical practice. Rather, they are
broad and applicable to other fields such as economics, politics, education, and so on. He deems it more appropriate that when outlining medical
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principles, we focus on the doctor–patient relationship and not on these
broad principles that can be applied to all aspects of life.
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Ahmed Raissouni
As has been mentioned before, it would be appropriate if we could provide these principles to governments as they develop their policies, in all
fields. They could even be included as constitutional principles. They
could also be a means for educating society about general morality and
how it can be applied in daily life. What I mean to say is that they are not
more specific to medicine than they are to economics, the stock market,
journalism, family matters, or education. From my perspective, they seem
to be chosen arbitrarily from scores of principles and, although the authors
claim that they are applicable to medicine and medical ethics, they in fact
apply to all aspects of life.
In my opinion, if one were to choose principles for the field of medicine, one must research issues that are more directly related to medicine
and/or principles that are more relevant to medical practice than to other
fields. However, Dr. Beauchamp has humbly and honestly recognized that
these principles are broad, general, and subject to additions or adjustments. So, for me at least, this misunderstanding has been overcome. The
question that remains is: Why were these four principles in particular
chosen, and how are they specific to medicine?
Tom Beauchamp
First of the all, the point was made that they are not specific to medicine,
and that is absolutely right. They are intentionally not specific to medicine. They are drawn from the common morality that we all share. There
is no doubt that they could be applied in many different areas. They are
going to get different applications within the different areas because of the
context. As I said earlier, business ethics is not journalism ethics and also
not medical ethics. However, as you begin to apply them in those areas,
you will get something that becomes highly specific to them. To put it in
another way, we draw from the common morality. The common morality
is that which we all share before we try to take it into medicine or we try
to take it anywhere else.
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Also, with the way in which the question was cast, it is as if these
issues are all about the doctor–patient relationship. Of course, that is not
the way we see it at all. It is a much broader territory of medicine. For
example, it covers the issues of public health. Public health is not about a
doctor–patient relationship per se. It involves a lot of policy structures, for
example, to protect the health of the public. We also have extensive discussions in the book on research ethics. Research ethics is not principally
about a patient–physician relationship except in the context of treatment.
Most research is not actually in a treatment context. So it has to be medicine broadly understood. The framework, the core principles, needs to be
general enough so it can be used in all of those different areas. Another
point made was that these principles apply to all areas of the moral life.
Yes, of course that is right. That is one reason we picked them: they are
general and apply very broadly in the moral life.
Finally, in terms of application in a medical context per se, I think
what happens is something like this, put simply: you have a principle like
respect for autonomy. It obviously applies all the way across the moral
life. However, when it comes to medicine, how does respect for autonomy
apply in the medical context? One way it applies, a major way, is with
informed consent. Informed consent is a doctrine that really is unique to
medicine and research. It has never been applied in any other context. We
explain what the connection is between respect for autonomy and what the
doctor owes the patient or a research subject, what informed consent is.
That then leads to further problems, particularly in treatment contexts. It
leads to problems of medical paternalism. So this is how it goes in making
these general principles specific to the medical context. One discussion
leads to another discussion, which leads to yet another discussion, and this
is basically the way Childress and I constructed the book. Eventually you
get this hopefully reasonably comprehensive book that is very well suited
to medicine broadly understood.
Jasser Auda
I remember a movie called Lost in Translation about missing the meaning
during interpretation. I listen to what you are saying and to the translation
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and, although the live interpreters’ translation is excellent, some vocabulary
needs examination and requires clarification. Perhaps we can discuss this
further another time. It is an important issue because Sheikh Al-Qaradaghi,
for instance, talked about naf‘. This Arabic word has the meaning of utility
(utilitarian) and benefit (beneficence) at the same time. The meaning of
beneficence is totally different from utilitarianism. In Arabic, we would say
utilitarianism is al-naf‘īyah al-māddīyah, and we would say beneficence is
maslahah. I believe when Dr. Beauchamp speaks of beneficence, he means
it in the maslahah sense and not in the materialistic or utilitarian sense,
which he himself rejects in his book.
Another example is when we talked about taqwá, which was translated as being God-fearing. However, if taqwá had been translated as
conscientiousness, then it could have been understood in a neutral meaning that applies to all physicians, whether religious or not.
One speaker also talked about the “atheist” culture. In his translation,
the translator did not mention atheism but instead used the term “secularism.” I think it was a good and correct translation because the translator
understood that the speaker meant secularism and not atheism. Yet, even
the term “secularism” in English requires a compatible Arabic meaning
because “secularism” in the English language does not necessarily mean
the absence of religion; rather, it means the separation of church and state,
which is another topic altogether. I think even if we are talking about
secularism in a Western understanding, it is not void of religion. The
American culture itself is full of religion, and it is only the state that is
secular.
Finally, Dr. Beauchamp talked about the “basis.” These values were
translated as mabādi’ (“principles”). However, this is not an accurate
translation (even though it is a translation I took part in admittedly).
Rather, the “basis” as described by Dr. Beauchamp means the fundamental [literally: “the mothers of ”] values. Dr. Beauchamp was saying that
these four are the “mothers of values,” not all the values. Scholars of
Islamic legal thought (usūlīyūn) would say they are the issues to which all
other issues refer back. So Dr. Beauchamp was talking about the “mothers
of values” and not “principles” in its exclusive meaning. He was talking
about the large fundamentals in the subject of values, as I understand it.
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Mohammed Ghaly
I also have some comments about translation issues. For example, I think
Sheikh Al-Qaradaghi discussed the integration of achieving benefit
(beneficence) and preventing harm (nonmaleficence). Beneficence was
translated as ihsān in Arabic, which is not entirely correct because ihsān
has a much more general meaning in Arabic, and Dr. Beauchamp is in fact
not talking about ihsān with all its implications. No doubt there are language technicalities that have impacted this discussion.
Mohammed Ali Al-Bar
I have seen the second, fifth, and seventh editions of Dr. Beauchamp’s
book. Being such a prominent figure, it is not surprising that
Dr. Beauchamp received many remarks and points of criticism, and it is
admirable how much he changed between one edition and the next. In
earlier editions of the book, the principle of autonomy took the shape of
Western liberal utilitarian philosophy and relied completely on that philosophy. It granted the human a great amount of personal freedom, though
this may have conflicted with other philosophies such as Kant’s philosophy, communitarian philosophies (i.e. Marxism or socialism), or different
religions. In the last edition in particular and in the research paper that was
disseminated to us, the tendency towards this philosophical direction
seems to have been reduced, although it is still present as far as I can see.
Coming now to social justice, I have a comment regarding something
I read in the fifth edition of Dr. Beauchamp’s book. There, he mentions
research done on a group of African-Americans who did not have health
insurance. They were emergency room patients and were treated by having their blood pressure measured there and being prescribed medicine for
high blood pressure. A study found that these patients were not benefiting
from this treatment for high blood pressure because they were not being
followed up by a doctor and in some cases were not able to purchase the
necessary medication for themselves. The conclusion was that there was
no need to concern themselves with this group of people. These were the
medical opinions given, but Dr. Beauchamp did not seem to criticize them.
Perhaps my English is not very strong, but this was my understanding of
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his book. It was clear to me that he did not criticize these opinions,
although he argues that he does.
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Mohammed Ghaly
Dr. Beauchamp has said that his criticism was clear in his text on social
justice.
Mohammed Ali Al-Bar
Once again, I am referring specifically to the fifth edition in this regard.
Dr. Beauchamp did not include criticism of the injustice and unfairness of
the system except in the seventh edition of the book as well as in the paper
we received from him. I am very pleased to see this change because
Dr. Beauchamp is a very prominent figure in the world of bioethics whose
ethical methodology impacts communities all around the world and thus
requires constant revisiting and revision. I am pleased to see that he has
started to review the sections on social justice and the distribution of
medical services.
It is difficult to justify that in the United States, which has some of the
finest doctors and the best hospitals and produces some of the best medical advancements, there are 50 million people without health insurance.
The United States spends around $8,000 per person, whereas countries in
Northern Europe (which spends $2,000–$3,000 per person) and others
like Malaysia (which spends $680 per person) spend far less. Yet the
infant mortality rate in Malaysia is lower than in the United States. This
is appalling. Even Cuba, which is not considered a very advanced country
by many standards, has a much better medical situation. In fact, many
Americans go to Cuba in order to receive free treatment. It is imperative
that the United States government provides medical insurance for its own
citizens. The insurance companies are monsters. A large company gets
cheap insurance if it has at least 10,000 employees, but small businesses
with fewer employees are charged higher prices. I am appalled at this
system and how the United States, with all its great minds, can accept
such exploitation. Ethically speaking, as a human being, I must criticize
this system as a failed system.
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Everyone looks to the American system as the ultimate system to be
followed. This is very far from the truth — and as a physician, I am talking specifically about the health sector. The system must be revisited. I
am from Saudi Arabia. Our government in Saudi Arabia blindly follows
the footsteps of the American system and consequently has huge
expenses that are even larger than that of the United States. This is catastrophic. The United States should not be viewed as the role model in
healthcare for the rest of the world. Perhaps Singapore, Sweden, Norway,
Switzerland, Canada, or the United Kingdom could potentially be role
models in this regard, but not the United States. The United States has the
highest number of doctors, the best resources, the best brains, and the
best hospitals, yet these excellent services do not reach all people; they
are only accessible to a small group of people. There are a few millionaires in the United States who have access to everything, but there is a
larger group of people who do not have access to proper medical services. This is an unjust system.
Mohammed Ghaly
Dr. Al-Bar’s comments can be divided into two main points. The first
point concerns the changes that occurred between editions of your book.
Were these changes due to a change in ideas and perceptions? Are you and
Dr. Childress busy now adding ethical values, principles, etc.? The second
point concerns your ethical stand regarding what is happening in the
health sector in the United States in terms of justice. I will give you a
chance to comment on these two points, Dr. Beauchamp, but first Sheikh
Abu Ghuddah would like to comment on the subject of social justice and
the related Islamic point of view.
Abdul Sattar Abu Ghuddah
Earlier I discussed the concept of justice in the distribution of social services. Social services were distributed well, by means of the endowment
system. Public hospitals were established by generous individuals through
charity in the form of endowments. These hospitals used to be open to
everyone for free. All medical services including residence, prescription,
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Script of Oral Discussions (Day 1, Session 3) 163
medication, treatment, good nutrition, and care for hygiene were free of
charge. I also mentioned that one of the doctors, Dr. Ahmad Issa, wrote a
400-page book1 describing hospitals during the Islamic civilization. These
hospitals used to be called bīmāristān. Bīmār is a patient and istān is a
place. In other words, the hospitals were called “the place of patients.”
This book highlighted that in every Islamic capital, or in every major city,
there used to be a large bīmāristān like a medical city and included a
school for new doctors, who were educated and assessed by the doctorin-chief. This was all for free, made possible by the contributions of
generous individuals, whether rulers or citizens.
This created environments of social justice that ensured the distribution
of medical and health services for free without any discrimination between
those who did and those who did not have medical insurance. Any human
suffering from pain or illness could go to the bīmāristān, where he would
be diagnosed and issued medication even if his case was a minor one. If
there was a need for him to sleep in the hospital, he would be admitted for
several days if necessary, until he recovered completely, God willing.
These are examples from our Islamic civilization that are thoroughly documented. Basically, these huge hospitals could be found in every major
Islamic city and were sustained through the endowment system.
Tom Beauchamp
First of all, a question has been raised about whether there are differences
across the editions. The answer is yes. If you go back to the first edition
and then look at the seventh edition, there have been vast changes. One
thing to bear in mind is that when we started, there was nothing. That is
to say, we had nothing to work from because there was no biomedical
ethics. There were no principles of biomedical ethics, at least not in a
moral secular context. So yes, there have been quite a few changes over
the years as the field has advanced, and the book would try to take account
of those advances.
1
Editor’s note: It seems the speaker is referring to: Ahmad ‘Isa (1938). The History of the
Bimaristans in Islam (Tārīkh al-bīmāristānāt f ī al-Islām). Damascus: Jamiat al-Tamaddun
al-Islami.
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There was a point about liberalism in particular. I would say liberalism
is no longer discussed much at all. It was discussed in our book more during a period in which communitarian theories were getting a great deal of
attention. Communitarian theories are nowadays not receiving very much
attention. Consequently, the discussion of liberalism and communitarianism has been reduced. At the same time, we have increased the discussion
of rights, human rights in particular. There was a big change in the seventh
edition about discussion of rights, and there has been some clarification of
the theory of justice. I would say what has happened there is that the
theoretical side has increased and the conceptual side (just analyzing the
concept of justice) has been reduced somewhat. I do think that there is
the same treatment of the problem presented by Weinstein and Stason, the
hypertension problem. There is the very same treatment in our book, in
the fifth edition and in the seventh edition. The important thing in this
regard is you should read the chapter on justice, not just the chapter where
we are dealing with Weinstein and Stason and hypertension. This is
because in that chapter we deal with the utilitarian character of this theory.
We are not trying to deal with our theory of justice at all, so you have to
get those together.
Now there were a number of points about the United States system.
The United States system is, in my opinion, a morally outrageous system.
I think we are largely in agreement there. I would also agree that insurance companies in particular, but not so much federal insurance since
federal insurance in the United States is actually quite good in many
respects for those people that it covers. Insurance companies, however,
which of course cover most people in the country, I would agree, are quite
greedy. It is also out of hand because of certain political features in the
American system, lobbying in particular because they have a lot of power
through lobbies. I think a part of this is what you refer to as materialism.
Materialism is not a term that we use much any longer. Many years ago,
it was used a great deal in these discussions, but I think I understand what
you mean by it.
It should be borne in mind that here in the United States we do have
a new law that is just going into effect, the Affordable Care Act. The
Affordable Care Act brings the laws of this country much more in line
with European countries like Germany and Switzerland, for example.
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They were studied very carefully in the construction of the new law here.
We are yet to see if the coverage will be as complete in this country as it
is in many other countries. Actually, one should be cautious in predicting
that too because things might actually get worse. My own belief is that
things are going to get worse in most countries. The very simple reason
for this is money. The rising cost of the technology that is required to
produce first-rate medicine for everyone increases dramatically every
year. It is unclear how much the economic system in different countries
can keep up with it. I am mildly pessimistic there, although I am mildly
optimistic that the new system that we have in the United States will be
an improvement. Also, it is very important to separate the medical system
in the United States from the insurance system. They often are not separated, particularly by politicians in this country. That is a huge mistake in
my view. Insurance is totally separate from medicine. What people should
concentrate their criticisms on, I think, are the insurance scheme and how
people get reimbursed for their costs. You might put it in the following
way. We have a terrible insurance system in the United States for all the
reasons that were mentioned about greed and so on. We have a very good
medical system. What we have to do is get the two together so that we
cover more people. I think that covers most of the points.
Mohammed Ghaly
Dr. Beauchamp, I would like to ask a question about an issue you mentioned in your paper and in your presentation. It concerns the problem of
structuring, organizing, and prioritizing the four principles. There is a big
emphasis on autonomy, and some say that you give it priority over the rest
of the other principles. How do you prioritize and organize these principles, or does it depend on the context?
Tom Beauchamp
As a quick answer to that question, it all depends on the context. There is
no prioritization given to any one of these principles. I do not see how it
is even possible to contemplate doing that because you want to apply the
principles or put them to work in a certain context, and some are simply
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going to be much more important than others. Take my example of informed
consent, for instance. Respect for autonomy turns out to be remarkably
important in most informed consent contexts. It does not follow, however,
that beneficence or nonmaleficence in particular are not important in an
informed consent context. I think they are very important. After all, protecting people against harm is part of the rationale of having an informed consent, but respect for autonomy is particularly important there. It is even
more so when you have refusals of treatment — not an informed consent to
a treatment but an informed refusal of a treatment.
In other contexts, for example, we have just been discussing healthcare systems and coverage for people, respect for autonomy is not very
important in those contexts by comparison to justice. Justice really
becomes all-important. I think that is true in the national system, and I
think it is true internationally as well. So you have to look at each given
context and what rises to the surface as the most important set of considerations and specify accordingly. So I think maybe the direct answer to
your question is no a priori prioritization ever works. You have to look
carefully at the context and what is needed in that context.
Annelien Bredenoord
I have one question. You started by saying that the principle of respect for
autonomy has been deeply misunderstood, and I think it might be interesting for our discussion if you could further elaborate on that because
I think it has not only been misunderstood by Western critics but particularly also by Asian or Islamic critics. I would be interested to hear from
you what exactly has been the misunderstanding of autonomy. Also, do
you see differences between different cultures on how they conceive this
concept?
Mohammed Ghaly
Just to add to that, some intellectuals and scholars explain the principle of
autonomy to mean that a patient has full freedom to do whatever he or she
wants. Could you please elaborate on that too?
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Tom Beauchamp
First about the principle of respect for autonomy and how it has been
misunderstood and what the proper application is. Let us first deal with
the question of why it has been misunderstood. I am honestly not sure
about this, but the one thing I feel fairly strongly about is that it is not an
East–West difference as you can tell from what I said in my talk. I do not
believe in East–West differences. As best I can see, historically the first
criticisms outside the United States of our theory of autonomy actually
came from Europe and from a very surprising source. For example, one
of the early critics was Professor Søren Holm, who himself is Scandinavian
and is now teaching in the United Kingdom. He was unhappy with the
idea that respect for autonomy was a basic principle of biomedical ethics.
From his perspective, it was not, and he thought that it basically came out
of the American culture. This is something that I have heard all over the
world, so it has to be something that has bothered a number of people: that
it is really not a universal principle and instead is this sort of individualism of the United States that is being brought in as if it were a universal
principle. I think that is a huge mistake, but there is no doubt that a number of people have thought that. So one source then is the framing of the
language of autonomy in terms of individualism or egoism or something
like that.
Also, because of the rise of political philosophy and the importance in
political philosophy of liberalism, autonomy has been thought to be necessarily attached to a political philosophy of liberalism, which I think is
not true. Now it certainly is true that a liberal political philosophy might
pay great attention to the principle of respect for autonomy, but the principle of respect for autonomy is independent of any particular political
philosophy. Nonetheless, I think that has been a source of the problem.
The last-mentioned problem is the one of absolute freedom. If you
look at the early criticisms that emerged from the medical literature — this
was true not only in the United States but also internationally — that was
a common interpretation of the idea of respect for autonomy. It made the
patient have the upper hand rather than the doctor having the upper hand.
The patient had absolute freedom to reject what the doctor is recommending, and so on. I think what I did was to “absolutize” the principle of
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autonomy in a way in which I have tried to make clear. We simply do not
do it, as it does not have any kind of absolutist value of this sort. We are
not at the moment trying to say what is correct and what is incorrect so
much as, why did we get these many different misinterpretations? I think
basically those are the reasons for these misinterpretations, although I am
sure there are other reasons as well.
Hassan Chamsi-Pasha
Thank you for this exceptional contribution, Dr. Beauchamp. I have two
comments. The first is about preventive medicine. As you know, in the
West and particularly in the United States, most of the money is spent on
treatment — like, as you said, on new gadgets like internal cardiac defibrillators or cardiac resynchronization therapy, etc. — while very little is
spent on prevention. I will give a small example. An ICD or internal cardiac defibrillator reduces mortality by about 30 percent in those patients
who have had a heart attack. This costs about $25,000 and according to
American guidelines it is a Class One indication. The same applies to the
flu vaccine for cardiac patients. It reduces mortality also by about 30 percent, and the vaccine only costs about $25. Not much attention is paid to
the flu vaccine because not many people make money out of it — $25 is
nothing — while companies push for the internal cardiac defibrillator.
This is where most of the money goes. This is a very important issue, in
my opinion: that we spend very little on preventive medicine, on reducing
the risks of coronary artery disease, while we spend billions and billions
of dollars on treating heart disease.
The second comment is about respect for autonomy. As a cardiologist,
I can say that while we undoubtedly respect the importance of the
informed consent of a patient, we do not take any patient for cardiac catheterization or cardiac surgery without informing one of his relatives at
least. In this society, in the Eastern culture, the family is very supportive,
and they ask to know and want to know about any procedure that will be
undergone by their father, their mother, their sister, or their brother. So we
do not take any patient for cardiac surgery without informing the family.
This is completely different from what happens in the West. Once again,
I will give a small example. Last week, I had a 24-year-old female who
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had five congenital anomalies. She was also anemic and hypoxic. I was
asked to do a transesophageal echo for her, but I said I would not do it
without informing the family first because this is a risky procedure. It is a
semi-invasive transesophageal echocardiography, and I could expose her
to danger. I would not put my transesophageal probe in her throat and
expose her to the danger of going into cardiac arrest or at least becoming
hypoxic and put on a ventilator without informing the family so that they
are aware of what I am doing. I would also like to hear your comments
about this please.
Tom Beauchamp
From my perspective those are very congenial questions. On the points
about preventive medicine, I could not agree with you more. You gave us
some interesting examples about lowering costs or how low the costs are,
and what the product is. One of my favorite examples is preventing catheter infection in ICUs. I like this example because it is completely free. It
does not cost anything to have a program in which you wash your hands
and go through several other things that prevent catheter infections. It
costs nothing, and it saves not just a few lives — it saves hundreds of
thousands of lives that are lost from catheter infections. It is an injustice
in the system that we do not lay greater emphasis on preventive medicine
of just this sort that I think you and I would agree on.
Secondly, on the part about informing the family, this interests me a
little bit because you seem to introduce again a difference between the East
and the West. I have not found that to be the case. I think that internationally there is a great deal of interest in effectively all cultures on proper
information for the family. There are some differences as to what proper
information is and exactly how to do it, but I think internationally there is
very little difference now. Informed consent is more or less required everywhere. We are still in the process, though, of people understanding this
very well. I was recently at a conference in Japan, and a professor from
Japan and I were both giving talks about informed consent. He said in his
talk that it is now undoubtedly a worldwide phenomenon and that it has
been very carefully studied and so on. His audience in Japan was in disbelief. They responded, “But we do not do that kind of informed consent
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in Japan.” He said, “Yes we do, you just do not know about it.” In other
words, the rise of informed consent in the way in which it has been
infused through systems around the world has been so rapid that a lot of
people are simply behind the times about how much it is done. This is true
in terms of both first party and what you were talking about, which is third
party (the family). So I think I am in complete agreement with you. I just
would not want to make the East–West distinction that you at one point
suggested.
Tariq Ramadan
What is the translation of the word “beneficence” in Arabic? Is ihsān not
acceptable? Dr. Jasser spoke about maslahah. What Arabic translation for
“autonomy”?
Mohammed Ghaly
Dr. Beauchamp, if you have comments to offer, please go ahead.
Tom Beauchamp
Beneficence divides down into different parts. I will read what I said earlier. Beneficence represents a group of principles requiring both lessening
of and prevention of harm as well as provision of benefits to others. That
is as good of a short definition as I can give you of beneficence.
Mohammed Ali Al-Bar
I think the word ihsān [translated by the Arabic-to-English interpreter as
“philanthropy”] is a good translation for beneficence because beneficence
in medical terms, from the time of Hippocrates until today, means that one
should be good to the patient in all possible ways. This does not only refer
to providing him with drugs or treating him well but also trying to do your
utmost to serve the patient. That is really what ihsān is about. It is about
striving to be perfect in your treatment of the patient. In other words, you
should be nice and good to him, treat his illness, alleviate his pain, treat
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him psychologically and do everything you can to treat him. So I think
ihsān will make a good translation for beneficence. Autonomy is a lot
more difficult to translate because it has to do with the individual, the
person.
Tom Beauchamp
No doubt philanthropy is a word that is going to be used somewhat differently in different cultures, and there will be different understandings of it
in English. Ordinarily in English, we would not use the terms beneficence
and philanthropy as synonymous. However, philanthropy is one kind of
beneficence, there is no doubt about that. What makes it more complicated in the context we are in is that I am thinking of beneficence as
a principle of obligation. You are obligated to provide these benefits.
Ordinarily, philanthropy is not considered something you are obligated to
do but rather is a moral ideal in the moral life. It is something that you can
do to provide goods or services for others, but it is not something that is
obligatory on you to do. That is the way I would draw the distinctions
here. They are close but not identical.
Mohammed Ghaly
Dr. Beauchamp has further complicated the matter but in a beneficial way.
He stated that philanthropy is a type of beneficence but it is not mandatory
or obligatory. He is right in that beneficence is obligatory and that [the
Arabic word] ihsān does in fact refer to something more than obligatory.
Mohammed Ali Al-Bar
In his book, Dr. Beauchamp discussed supererogatory acts and mandatory
duties, and he did distinguish between them. Islamic law also includes this
distinction. We have mandatory duties, and we have supererogatory philanthropic actions.
I differ with him in one example he mentioned concerning the story
about the Samaritan in the Bible. Dr. Beauchamp says that Jesus gave an
example to his companions through this Samaritan. While on a journey,
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the Samaritan found someone on the way who was injured, so he stopped.
By the way, the Samaritans were a group looked down upon by the Jews.
The Samaritan went to the injured man, tried to treat his injuries, and
entrusted him to someone, promising to come back to take care of him
and cover the costs of doing so. Indeed, the gentleman did get better.
Dr. Beauchamp considered this act to be supererogatory, not mandatory.
From the words of Jesus, peace be upon him, in the Gospel, it was
clear that Jesus was telling his companions and disciples that this is the
least you can do for the sick person; in other words, it is obligatory.
According to Dr. Beauchamp, this is not obligatory, and I have an issue
with that. From my perspective, what Jesus, peace be upon him, said
clarifies how much people should care about other people. The gentleman
is on the street; he might die. It is an obligation to save his life. The position taken by Jesus, peace be upon him, was very noble. Of course, he is
a prophet and is among the best of humankind, but nevertheless he was
setting an example for his disciples and companions that this is the least
of the mandatory. Dr. Beauchamp considered this to be supererogatory,
not mandatory.
Jasser Auda
Dr. Beauchamp said the definition of beneficence was basically about
bringing about good and preventing harm. The definition translates seamlessly to an Arabic phrase we ourselves use very often: tahqīq al-maslahah
(realizing benefit) and dar’ al-mafsadah (repelling harm), respectively.
In regards to autonomy, it was translated as istiqlālīyah, which
means independence and is different [from autonomy]. Autonomy was
also translated as dhātīyah, which means individualism. Autonomy was
also translated as hurrīyah (freedom), but I do not think autonomy is
about freedom in its absolute sense. Rather, autonomy should be translated as hurrīyat al-qarār (“the freedom of action” [a person’s freedom
to act as he chooses]), which is the Islamic term. I think hurrīyat
al-qarār is the translation closest to the meaning of autonomy. Autonomy
is not about istiqlālīyah or dhātīyah, both of which are very different
from autonomy.
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Mohammed Ali Al-Bar
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Autonomy is part and parcel of independence and individuality according
to liberalist thought.
Jasser Auda
Dr. Beauchamp has clarified that he is against the liberalist approach.
So we have to be aware of all definitions.
Mohammed Ghaly
My personal opinion — and God knows best — is that beneficence and
nonmaleficence are jalb al-masālih (bringing about benefits) and dar’
al-mafāsid (repelling harms), respectively. That is how they should be
translated in Islamic legal terminology. Alternatively, we can say tahqīq
al-maslahah (realizing benefit) and daf‘ al-adhá (repelling harm) if we
want the general Arabic translation. However, using the term ihsān is
problematic because ihsān is also about perfecting work, and it also
means giving money to people in charity. Furthermore in the Islamic tradition, ihsān is a very complex and rich concept and encompasses much
more than what we are talking about. For this reason, Sheikh Al-Qaradaghi
had a point when he said that since ihsān encompasses both concepts of
beneficence and nonmaleficence (and more), there is no need to include
them as separate principles. Therefore, using ihsān could be accurate if
we combined the two concepts of beneficence and nonmaleficence.
Dr. Beauchamp is opposed to this because beneficence is about doing and
nonmaleficence is about not doing.
I think the bigger issue is autonomy. The closest we got was the comment made by Dr. Jasser that it is about freedom of action, and we might
also add the phrase “with responsibility.” Even in Dr. Beauchamp’s paper,
he says it is not only about liberty, but it also has to do with agency. So it
is freedom plus action plus bearing the responsibility of that action.
Dr. Beauchamp clarified that among the most commonly misunderstood
principles is autonomy. He clarified that, for example, autonomy may
occasionally involve limiting and constraining the freedom of the patient.
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So it is not necessarily about allowing the patient to do whatever he wants.
Therefore, I think that “freedom of action with responsibility” might be a
good translation.
Jasser Auda
However, I think the concept of independence is indeed present in the
meaning of autonomy.
Mohammed Ghaly
Yes, independence is there, but it is not absolute.
Jasser Auda
Yes, it is not absolute, but it is there. I think autonomy cannot be translated
into hurrīyah (freedom) alone or istiqlālīyah (independence) alone. I think
it requires the use of more than one term.
Mohammed Ghaly
Of course, one of the beautiful things about our meeting today is the issue
of terminology. When different ideas meet, it is imperative to fix the
definitions of the terms we use. Many of you know what Hunayn bin
Ishaq, an Arab philosopher, had to go through when he translated Greek
texts. He would constantly amend, review, and reamend his own translations. Sometimes he would recognize that certain concepts were simply
too complex for him to translate concisely. No doubt the translation of
philosophical concepts especially, as in our discussion today on bioethics,
requires review several times over.
Tom Beauchamp
I have a comment on the Samaritan story. I think it is quite clear in the
way in which we frame the language of a moral ideal versus that which
is obligatory today. What the Samaritan did in the story is a matter of
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Script of Oral Discussions (Day 1, Session 3) 175
following a moral idea and not something that is morally obligatory. Of
course, that does not mean that you could not have a religion in which it
was made mandatory. Of course you could.
The full story of what the Samaritan did is really quite remarkable. It
would be the equivalent today of us finding someone on the street who is
very sick and ill and probably starving and injured, getting them in our
car, taking them to a hospital, putting them in the hospital, paying for
the cost of their hospitalization, taking care of them while they are in the
hospital and when they are released from the hospital, taking them home
and continuing to take care of them and so on. That surely has got to
be supererogatory in the matter of our moral ideals. That is the reason why
it is interpreted in that way.
I also have a comment on the meaning of autonomy. Originally,
autonomy comes from the Greek word autonomos and originally had a
political application, not a moral application. In the context of political
states, it basically meant sovereignty. As it got translated into moral philosophy, the meaning basically became “self-rule” or giving oneself the
law, which could be the moral law or could just be giving oneself a different kind of rule. As you rightly pointed out, in my way of interpreting it,
the critical context is there is liberty — that is to say, there is no controlling influence that is operative — and there is agency on the part of the
individual in giving oneself one’s reason, one’s rule, one’s principle or
whatever.
I do not think that in any respect Childress and I speak against liberalism in talking about autonomy, but we certainly do not speak in favor
of it either, except insofar [the following is true]. If you believe that support of human rights theory is inherently a part of a liberal political philosophy, then we do place it in the liberal political context because we
certainly believe strongly in human rights. However, in general, we try to
stay away from that particular commitment — that is to say a liberal
political philosophy.
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14:6
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Script of Oral Discussions
(Day 2, Session 3)
After Tom Beauchamp presented his paper, the following discussion
took place.
Mohammed Ghaly
Dr. Beauchamp said the four principles are universal on the one hand and
localized and particular on the other. They are neither purely universal nor
purely particular. He explained that the four principles are universal in
principle, meaning everyone does agree that justice, beneficence, nonmaleficence, and autonomy are important. However, applying the principles
to make them particular is a different issue altogether. The difference does
not emerge only because of adherence to a certain religion or culture;
rather, differences may emerge because of differences in various fields
and disciplines. For example, when we apply justice in the field of economics, medicine, or politics, each application yields a different outcome.
So despite the universality of the principle, its applications do differ even
for individuals who adhere to the same religion. It is not about religions
but rather about differences inherent in various disciplines and professions. Still, this does not mean that the four principles are not universal.
177
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So Dr. Beauchamp maintains that part of it is universal and another part
is particular to the local circumstances where it is applied.
Dr. Beauchamp also talked about cultural diversity. He realizes that a
universal morality may seem threatening to cultural diversity. However,
he thinks the opposite is actually true: the principles support and encourage cultural diversity. Cultural diversity does not necessarily mean pluralism, and Dr. Beauchamp thinks that if we accept pluralism, this will
contribute to a “melting” [or softening] of ethics. Rather, if we all accept
the same principles but differ in our implementation of those principles
because of our different cultures, this is closer to living harmoniously with
one another. Therefore, the presence of universal principles does not cancel out cultural diversity. The same goes for religious diversity.
Ali Al-Qaradaghi
Dr. Beauchamp addressed some of the questions raised yesterday about
the fact that the four principles are not specific to medicine. He clarified
that even though the principles are general, they can be applied specifically to medical issues. I share this opinion. I think the generality of the
principles does not contradict the specificity of their application to medicine. Similarly, if we take the higher objectives of Sharia as a framework,
they themselves will be ratified in the specification process.
However, I would like to make some clarifications. Islam is creed,
law, ethics, and ritual acts of worship. Ritual acts of worship are about the
religious behavior and conduct of the faithful. While they are not explicitly or manifestly about ethics, they do have ethical ramifications. God
says, “…Indeed, prayer prohibits immorality and wrongdoing…” (Qur’an
29:45). Although the act of prayer itself is not about ethics, it still has
ethical implications. This also applies to almsgiving (zakāh). God says,
“Take, [O, Muhammad], from their wealth a charity by which you purify
them and cause them increase” (Qur’an 9:103). There is a difference
between the action and the effect, between the means and the end.
Therefore, in my opinion, religious specificities do remain within the
realm of ritual acts of worship, while general, unchanging ethics are part
of what Imam Al-Shatibi called al-dīn al-‘ām (general religion), and they
are part of human nature (fitrah).
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Script of Oral Discussions (Day 2, Session 3) 179
We mentioned previously the following section from a Qur’anic
verse: “The innate disposition [fitrah] from God upon which He originated (or created) mankind” (Qur’an 30:30). The verse then continues,
“That is the upright religion.” In other words, God made the human with
an innate disposition (fitrah) that is agreed upon and shared by all humanity and people of religion as part of the steadfast, unchangeable religion.
Again, we are talking about things that are agreed upon, such as prohibiting immorality or wrongdoing — even if we may differ as to what exactly
is immoral or wrong. In other words, these general ethics are part and
parcel of the human’s innate disposition (fitrah), and before, simultaneously, or after, they became part of religion. Each religion contributed
certain specifics or specifications to these ethics, but the foundations of
ethics do not at all differ between religions.
So I just wanted to clarify to Dr. Beauchamp the distinction between
ritual acts of worship — which are not ethics but have certain ethical
implications — like prayer and between general ethics that can be applied
to all humanity. In other words, if we examine the Islamic system as a
whole, including the ethical values it calls for, I think it would be accepted
by all rational thinking people across the world.
One more thing: differences between cultures and peoples should be
taken into consideration, but only after a firm acceptance of the core principles. It is for this reason that Sharia contains absolute texts that are
immutable, unchanging across time and place, and whose meanings are
clear-cut. Only their applications may change according to circumstances
of time and place.
Mohammed Ali Al-Bar
I have a comment related to the ethics of medical research or biological
research more generally. There are a number of examples of harms that
resulted from human experimentation, starting from the beginning of the
20th century up until the beginning of the 21st century. The first event that
drew attention to and laid the foundations for these issues was the trials of
Nuremberg in which the Nazis had conducted experiments on the Jews.
This led to a lot of controversy, and the doctors participating in the inhumane human experiments were executed. It was later revealed that the
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same Nuremberg experiments carried out by the Nazis were replicated in
America and Europe in an even more disgraceful manner. This is recorded
in medical research history. I referred to this in my own research and
highlighted the mass killings that occurred due to these events. Arising
from this, foundations and regulations for medical research were established. One example is the Belmont Report. They are very good foundations and regulations, but they can be manipulated and circumvented,
even in the United States.
As for nations of the Third World, these regulations did not exist in
the first place, so it was easy to get away with unethical medical research.
I will give you a case in point. In 1996, the company Pfizer conducted
experiments on Nigerian children. It was testing a new medication for
meningitis. They claimed this medication was ready and licensed and that
they were donating it to the poor. Nigeria was initially very pleased with
this, but it ended up killing a number of children and injured many others.
Once this was exposed, the Nigerian government sued the company and
received $75 million in compensation after the company confessed and
acknowledged its actions. In 2009, Pfizer was also penalized by the
American F.D.A. with a $2.3 billion fine for the simple reason that the
company had conducted experiments on four of their medications at a
time when they were “off label.” They were without a license and yet
were distributed to doctors who used them without official recognition by
the F.D.A. This was considered unlawful, and the F.D.A. fined the company with $2.3 billion, although no one was harmed. Compare this with
the Nigerian case in which children were killed and many others were
harmed and yet the compensation was only about $75 million, which of
course did not trickle down to the victims.
In 2012, the British drug maker GlaxoSmithKline was fined approximately $3 billion for the biggest fraud in American healthcare. Keep in
mind that this took place in 2012, which is only a few months ago. This
company was fined for distributing 10 drugs, including Avandia antidiabetic, marketed globally as an efficacious drug for diabetes but later
as causing heart disease. The company was well aware of the side effect
but concealed it. Experts in the field stated that $3 billion is a trivial
amount for the company, given the approximately $30 billion it had
reaped from those 10 drugs. This was in the United States. How much did
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Script of Oral Discussions (Day 2, Session 3) 181
they pay the Third World nations where these 10 drugs were distributed?
Nothing at all.
I also have a personal experience that took place in Saudi Arabia.
There are new drugs that are used to treat cancer patients and other serious
diseases. I was a member of some ethical committees responsible for permitting or restricting the experimenting of drugs on people. I was pleasantly surprised that Pfizer and other leading companies like Glaxo would
state that a certain drug might cause blindness, heart disease, or other
harm, etc. This was good transparent practice. However, included in the
same report was a section stating that if you incur one of these diseases or
pass away, the company would not be responsible for any compensation,
and treatment is based on your own health insurance. I was completely
opposed to the company’s refusal to treat or compensate the patient who
incurred a disease due to this drug, especially because the company
admits that the drug may cause certain diseases. I resigned from one of the
committees because the chair of the committee used to receive money
from the company itself and he wanted us to sign the report, and of course
I was against that. If this is what happens in a rich country like Saudi
Arabia, where its residents are not much in need of money, imagine what
happens in poor countries.
As made evident by these examples, there is outrageous exploitation
taking place by Western leading companies in the Third World. These
companies are allowed to conduct research through bribing researchers
and high profile personalities in order to facilitate the circulation and
usage of the experimental drug. They do not provide any sort of compensation for the poor people who suffer illnesses due to these drugs, even
though companies have started admitting that many suffer due to their
experimental drugs. Acknowledgement is a good first step, but there is a
necessary second step. When I refused these actions on many occasions,
I found that my opposition led to the company being forced to acknowledge the need for it to compensate — or at least medically treat — those
affected by the drug. This is a positive thing; it suggests that if doctors
stand up for ethical issues, the companies might meet ethical demands,
although admittedly in most cases the companies do not end up meeting
them, especially in Third World companies. I am confident that ethical
demands are met in the United States but only after the company is
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exposed to the public. The point I am trying to make is that manipulation
and fraud continues to take place even in the United States. In the Third
World, fraud occurs even more so and on a larger scale, as people can be
bribed with small amounts of money.
Mohammed Ghaly
Dr. Al-Bar has provided many examples over the past two days regarding
breaches and violations that happen despite the existence of principles of
medical ethics and despite there being agreements and contracts involving
those ethics. In personal exchanges between Dr. Al-Bar and myself,
I communicated to him an idea that is my own personal opinion and may
not be completely correct. It is that one of the main reasons these violations were exposed was the existence of the field of medical ethics. If we
did not agree upon certain principles, we could not have called them violations. It follows that these principles are exposing, and without them
many things would have gone unnoticed. Of course, it is not enough to
have principles or rules; another important matter is the mechanisms by
which to apply the principles. This could be one question for our final
day’s discussions.
Hassan Chamsi-Pasha
My question is about the recent concept of defensive medicine that has
become widespread. Doctors sometimes conduct X-ray examinations or
medical interventions in order to protect themselves from blame or legal
action that may arise due to them not carrying out a certain test or medical
procedure. Despite this, the cost of medical insurance for doctors has
greatly increased especially in the United States and Europe and particularly for gynecologists and obstetricians. I believe Dr. Beauchamp knows
that the insurance rate or insurance fees on these doctors have increased
significantly.
My question is: To what extent can we apply the four principles to
limit the spread of the concept of defensive medicine? It may cause the
patient unnecessary complications and yet many doctors do it to protect
themselves or out of fear of accusations from their patients. I will also ask
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why this phenomenon has been spreading although the four principles
have also been spreading widely over the last 30 or 40 years in the United
States and Europe?
Mohammed Ghaly
Another question to note is how the principles of biomedical ethics or
biomedical ethics as a field in general can be more effective and how
satisfied are we with the status quo of medicine and medical ethics in
general?
Abdullah Bin Bayyah
Edgar Morin’s book, written in French, La Voie: Pour l’Avenir de
l’humanité (The Way: For the Future of Humanity) covers many of the
issues being spoken about here because they are of interest to the future
of humanity. According to Edgar Morin, scientific research makes promises et menaces (promises and threats). It promises benefits, but it also
warns of evils or harms. As I thought about this I came to the conclusion
that this is part of an important principle in Islam jurisprudence: removing
the means to error (sadd al-dharā’i‘). Muslim scholars agree on the necessity of avoiding harm if it is certain, but if the harm is not certain their
opinions start to differ.
The matter has to do with verifying the underlying character of certain
issues (tahqīq al-manāt), which is a topic we have been studying and will
be tackling in an upcoming conference in Kuwait. We are interested in
tahqīq al-manāt in both the current reality (wāqi‘) and predictable incidents of the future (tawaqqu‘). We have been studying this topic for a year
or so, and we find that the entirety of Islamic jurisprudence (fiqh) must be
reviewed in light of both current reality and future expectations because
the reality of the modern world in the fields of economics, society, politics, scientific discoveries, and international relations is unprecedented in
human history. Therefore, we need to review the entirety of Islamic law.
So far, we have categorized it into disciplines and domains. The current
challenge is how to generate a clear description of the reality. According
to the system of an early Muslim scholar, Abu Hamid Al-Ghazali, there
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are five scales for qualifying reality in order to better understand it: the
scale of the senses, the scale of language, the scale of customs, the scale
of the intellect, and the scale of nature. He mentioned this in one book,
and I do not know of any other Muslim scholars who dealt with this in the
issue of tahqīq al-manāt. I see this as an incredibly important issue pertinent not only to Muslims, but to humanity at large.
Hence, in my opinion, there are two main issues that we need to
address. The first is ta’sīl, to develop a framework rooted in the Islamic
tradition. The second is tawsīl, to communicate this framework to the public. There is a problem that Dr. Al-Bar pointed out: although these ethics
and morals exist, people do not act according to them. This is because the
ethics and morals have failed to reach their consumers; they may have
only reached physicians and companies. The responsibility of industrial
capitalism is huge in this regard because industrial capitalism often runs
away from ethical responsibility, not only in the field of scientific
discoveries but also in the domains of labor, production, distribution, and
so on. We must say that this ruthless industrial capitalism must review and
re-evaluate itself.
Regarding other ethical values, whether they are religious, based on
tradition, or stemming from a social ethical system, it should help find an
end to the great greed that does not ask about why but rather about how:
How to acquire wealth? How to make a scientific discovery? However, the
question, “Why?” which is a philosophical question, necessarily must
precede the question, “How?” In tahqīq al-manāt, we established three
questions. The first question is, “What?” as in, “What did your Lord say?”
The second question is, “Why?” and this is the domain of ta‘līl (justification). The third is, “How?” and this is the domain of tanzīl (application).
We are speaking about the third, tanzīl. Here, ta’sīl is important and
tawsīl is important too. Communicating this knowledge and educating
societies about it is critical so that they may claim their own rights. There
have been discussions about harmful drugs administered to patients who
are unaware that the drugs they take are indeed harmful. I think often the
consumer is not aware of what is happening, so communication is imperative in this regard. As we said, the promotion and spread of knowledge
is key. Biological research studies must focus on preventing harm before
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seeking what we call “the fake interests” because the prevention of harm
is prioritized over the bringing about of interests.
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Abdul Sattar Abu Ghuddah
My question is about whether all the principles should be taken together
or whether there is some prioritization or ordering among them. Also,
Sheikh Al-Qaradaghi mentioned that the number of the higher objectives
of Sharia could reach nine, the ninth one being preservation of the environment. I would like to ask about the ordering of these objectives. We
believe the objectives must all be accepted, but do they follow a particular
order? Sheikh Raissouni mentioned that while the actual ordering is not
agreed upon, the concept of ordering is established.
Abdullah Bin Bayyah
In Chapters of the Higher Objectives (Mashāhid min al-maqāsid), I discussed the issue of ordering and I found that each higher objective or
principle has within itself levels. For example, some scholars say that
business or selling is counted among the group of needs (hājīyāt) while
Imam Al-Haramayn says it is among the group of necessities (darūrīyāt).
In fact, selling is of different types.
The early Muslim scholars did not reach a consensus on one ordering
for the necessities, although they did agree on the necessities being comprised of five benefits [to be preserved]: religion, life, offspring, the intellect, and wealth. Some of them prioritized religion over life — and this
was the majority opinion — while others prioritized life over religion, and
so they differed on the rest of the necessities.
Back to my earlier point, selling is sometimes considered a necessity
and at other times is considered a need. Selling food is among the necessities, based on the texts of Sharia, because of the necessity of food.
Selling luxury items is neither among the necessities nor is it among the
needs; it is counted among the luxuries (tahsīnīyāt).
Early Muslim scholars dealt with a number of detailed issues in
the medical field such as mercy killing. They said that mercy killing is
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prohibited in Islam. I point here to the words of the Maliki jurist al-Zurqani,
who said that expediting death is prohibited and that there came a time
in Egypt when physicians would hasten the death of patients whom they
deemed terminally ill. So these issues were relevant even then.
The early Muslim scholars also dealt with the question of the liability
(tadmīn) of the physician. They made a distinction between being liable
and being sinful. The scholars said that if a patient asks the physician to
amputate his or her hand — while the patient is healthy and completely
sane — the physician is not liable for complying with the patient’s request
[and thus would not pay a diyah], but the physician is considered to have
committed a sin.
Mohammed Ghaly
Dr. Beauchamp, I would like to reiterate the two main questions to you.
The first is the one I mentioned about how to make these general principles effective and what is your opinion on the current situation — is it
getting better or is it getting worse? The second question, which came
from Sheikh Abu Ghuddah, was about the four principles. Are they complementary? Are they one indivisible set that should be considered all
together, or can we take one principle and leave another? Also, is there a
hierarchy for the four principles? Can they be ranked from one to four or
not? If you have any further comments on what you have heard, also
please go ahead.
Tom Beauchamp
Let us talk a little bit about making them effective and how we can get to
a better situation and avoid the worse situations. As you know, I think
there is a methodology that underlies the so-called “principlist” approach,
and it has to do with the business of specification. Specification is not
something that one just wakes up one morning and says, “Well, I am
going to specify a principle in such a way.” At least it cannot be done
responsibly that way. It takes a lot of arguments and dealing extensively
with cases.
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Script of Oral Discussions (Day 2, Session 3) 187
For example, let us take the discussion that just occurred about the
cases presented by Dr. Al-Bar regarding Pfizer and GlaxoSmithKline.
This is an area I know a fair amount about. It is a very difficult territory;
there have been a lot of abuses in that area. There are also, however, some
fairly exemplary pharmaceutical companies that have bioethics committees, not only for human research but also in some cases for animal
research. So, it is something that can be controlled. It can be brought
under control, monitored, it can be supported from the position of the
CEO down to all employees. Unfortunately, though, most pharmaceutical
companies do not have a structure like that in place. Also, at least in the
United States, they are not very carefully monitored by the government
because they are private corporations and also because we do not have a
very good system, frankly, in the United States for monitoring these fundamentally ethical problems, the problems of Pfizer and GlaxoSmithKline
that Dr. Al-Bar was mentioning. I think the best solution is to have both
internal committees that debate these issues and formulate policies that
are then reviewed at a higher level as well as have external people as well.
There is really no way to shortcut this. It is similar to writing a book.
You do not get up one morning and write a book. It takes a lot of extensive
research and arguments and so on. The same applies to ethics. It takes
embedding the stuff in material and sometimes the material is highly
unfamiliar to people so they have to come to grips with it. Earlier I mentioned the discussion I had at a seminar in Japan where people simply did
not understand what informed consent was and how important it had
become, even in their own country. They had to be updated on what the
situation was and then they had to formulate the policies of informed
consent and informed refusal and so on in very difficult circumstances. So
that is just a way of saying there really is no shortcut. It takes extensive
debate and argument considering the examples and counter-examples,
looking into problems and how those problems can be rectified. It has to
be done both internally within organizations as well as by external observers and critics of those organizations. That would be my basic answer to
the first question.
The second question asked whether the four principles are complementary and do all the four go together as a set. Yes, I think they all four
go together as a set. That is the whole idea. As to whether they are
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complementary, I suppose it depends a little bit on what is meant by
complementary. I would rather use a term such as comprehensive. I think
they are reasonably comprehensive, and of course by specification they
can be made even more comprehensive.
The one thing that is important here that we have discussed a good bit
is the possibility of conflict. These principles can certainly constantly
encounter situations of conflict. The chief example I used in my talk yesterday was the problem of paternalism, where respect for autonomy
comes in conflict with beneficence or, since we are dealing with medicine,
medical beneficence. There is a constant potential for conflict between
respect for autonomy and beneficence. I would say the same thing here
that I was just saying in general: there really is no shortcut for this. I think
it is a huge mistake for people to say, well I am a paternalist or I am an
anti-paternalist. You have to argue each issue out as it comes along.
Paternalism can arise almost anywhere, not only in clinical medicine,
which is where people often think about it. It could also arise in, for example, public policy. Earlier someone mentioned the F.D.A. in the United
States. The F.D.A. is a paternalist organization. That is what it is in the
business to do. It is in the business of protecting you against yourself by
not allowing you to purchase certain kinds of medicine before they are
ready to be purchased in addition to requiring prescriptions. That is basically a paternalist organization. Is that good or is it bad? Well, maybe
some features of it are good and some features of it are bad. However, one
cannot just decide that a priori. It must be argued out at some length. That
is what I would say about them being complementary.
The third part is whether the principles can be prioritized. As I think
I said with some firmness yesterday, there is not. I do not believe in the
idea of prioritizing principles. I have never seen a system in which there
was an attempt at prioritizing that was successful. Professor John Rawls
wrote probably the best-known book of philosophy in the 20th century,
A Theory of Justice. He attempted to do this just with the principles of
justice in his case. I think that by almost all accounts it was a complete
failure. So even in the very best academic works or public policies where
prioritizing has been attempted, it simply does not work. The reason is
quite simple. In a policy or formulation of abstract principles, you cannot
anticipate all of the cases that will ultimately fall under those principles.
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Script of Oral Discussions (Day 2, Session 3) 189
Therefore, you cannot know how important one principle will be by
contrast to the other. To go back to the paternalism example, in some cases
it is extremely important to get a medicine started on a patient or to perform a medical intervention because otherwise they will die. Let us say
you have a severe threat that is operative. In other cases, there is not much
of a threat at all. It is a very small operation. Each situation presents a
different context with a different set of considerations that need to be balanced. So I am not a prioritizer; I am a balancer and a specification person
as you can see.
Tariq Ramadan
Earlier, Sheikh Raissouni asked a very important question: What is medicine? Dr. Beauchamp, you said you developed these principles in the
1970s because at that time bioethics did not exist. In other words, bioethics
is something specific, and medicine in earlier days is not the same as the
medicine we are talking about today. So while the papers presented during this seminar argue that there were similar issues [in medicine] before
and there are answers to these issues from the past, you are saying there
is a difference in the nature of medicine before and now. I believe this is
an important point worthy of discussion. So what exactly is the difference, and what exactly do you mean when you say nothing was there
before?
Tom Beauchamp
I certainly do not say that nothing was there before. Both medicine and
medical ethics have a history of several thousand years. Much of it is
interesting, but the important realization that occurred, I believe, was
closer to the 1960s. The realization began to seep in that most of it is quite
irrelevant to modern problems. That was the tipping point. Let me give
you a particular event that happened in my own life that had to do with
when I was recruited into bioethics by a man in medicine. He was an
obstetrician and gynecologist (OB/GYN) named André Hellegers. He was
the director of our institute at Georgetown University. When I got to know
André, he had the view, and I think it was fundamentally a right view, that
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medicine had completely lost its way because of developments in modern
medicine. It [medicine] thought that something like the Hippocratic
tradition was going to be a sufficient medical ethics because it had thought
in that way for centuries. In his view, and again I think he was correct, it
is utterly inadequate to resolve most of the problems that have come into
medicine.
Take one example that was occurring at that time regarding what to
do in the way of distributing dialysis machines. We suddenly had, in the
United States, legislation — a national law — that said everybody gets a
dialysis. Is that a right law? Do we do that with all of medicine? We never
had dialysis machines before, and generalizing from dialysis machines,
we never had anything like the kind of power in medicine, scientific
power, to actually cure people. Medicine for centuries and centuries had
been largely a matter of giving people hope with very little science behind it.
What happened in the early part of the 20th century was interesting. The
most notable country here was Germany because Germany was the most
advanced scientific country early on and began to refashion the way in
which medicine was taught along scientific lines. The United States began
to learn from the German example around the 1920s or so and began to
redesign all of its medical schools and its entire system.
So what was happening is the science was getting ahead of the ethics.
The ethics was not changing and yet the science advanced rapidly.
Suddenly there was this enormous amount of scientific research being
done and brought into medicine, and new technology developed and we
simply did not know what to do with it. Furthermore, the Hippocratic
tradition was not helping us at all. So when I talk about fundamental
change, that is the kind of fundamental change that I mean. You needed a
new biomedical ethics to come to grips with a period in which hundreds
of new problems that had no precedence at all in the Hippocratic tradition
were coming along.
I will give one example. In the Hippocratic tradition and all these
medical ethics traditions from thousands of years ago that I mentioned,
there is no research ethics whatsoever. Suddenly we found the major problems that we had had to do with, for example, cases like the Nuremberg
trials that someone mentioned earlier. That is very interesting because
the trial took place in Germany, the most scientifically advanced country
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Script of Oral Discussions (Day 2, Session 3) 191
in the world. One of the problems is that ethics had not kept up with
reality there. Of course you also had a crazy political regime in Germany,
but there was a parallel problem about the ethics.
Let us come back now to the question that was set in the 1970s, and
let us take research ethics as an example because it is the simplest one.
The discussion of research ethics really only began in the 1970s. Something like the four principles or the idea of having principles that can be
embedded in discussions of medical research was all new. It had to be
completely created because there was no precedence for it whatsoever.
Hence, when I make these sharp breaks and put it in that way, that is the
kind of thing I am talking about.
Tariq Ramadan
Just to follow up, would you say that with all the technology we have now
you would give a new definition to medicine, or is it the same?
Tom Beauchamp
That is a very good question. It is fundamentally a definitional or a conceptual question, and the territory has to be much broader. In other words, if
you are going to recast the definition, which it probably should be, the
territory will have to be a lot broader than it covers, and the ethics is going
to have to track the changes in that territory. Again, perhaps an example
would help a lot. In my career, I spent a great deal of time arguing — gently,
but arguing — with a colleague of mine named Edmund Pellegrino.
Pellegrino believes that the fundamental ethics in a clinical context, in
clinical medicine, has to do with the patient–physician relationship. He
views it as a one-on-one relationship, the doctor and the patient. That is
fundamentally what medicine is about, and it is fundamentally what medical ethics is about. I think that is far too narrow. Medicine is far, far more
than that. It infuses into territories like biomedical research, public health,
and so on in ways in which it has not in the past. The encounter between
physicians and patients is nothing like one-on-one anymore. So those are
just a couple of the many issues we have to think about in order to address
your question intelligently and comprehensively. Do I think there has been
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a fundamental change in the healthcare system? Absolutely I do, so in
terms of definitions, we have to catch up with what those changes are. This
will perhaps help us restructure and rethink the nature of the system as we
continue to create it.
Mohammed Ghaly
The change that has been occurring in medicine — and it is a fundamental
change as Dr. Beauchamp says — requires a fundamental change in the
ethics of medicine. I think it is not enough to point out that something that
occurred was ethically wrong. It is also necessary to figure out how to
proceed.
Tariq Ramadan
Given what Professor Beauchamp just mentioned about the fundamental
changes in medicine and the changing realities, I do not think it is possible
to order or prioritize the higher objectives of Sharia in any particular way.
Dr. Beauchamp says that there is no way to order the four principles in any
particular way; they form a set together. Given what I hear now about the
change in medicine and the new questions that arise, ordering does not
seem feasible. Is it possible now to maintain the order and prioritization
of the higher objectives of Sharia as they have been before?
Abdullah Bin Bayyah
It is possible to say that the higher objectives of Sharia are the products of
the human intellect, of human rationality, meaning what are the needs and
necessities of man on earth? For the religious person, Muslim and nonMuslim alike, the central point is the person’s relationship with God. That
is why they say religion. In this sense we mean religion in general, in the
sense stated in the verse, “He [God] has ordained for you of religion
what He enjoined upon Noah and that which We have revealed to you,
[O Muhammad], and what We enjoined upon Abraham and Moses and
Jesus — to establish the religion and not be divided therein…” (Qur’an
42:13). So we mean religion in the general sense of the word.
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Script of Oral Discussions (Day 2, Session 3) 193
Wealth is also one of the higher objectives of Sharia. Most scholars of
Islamic legal theory (uṣūlīyūn) put the higher objectives of Sharia in the
following order: religion, life, wealth, intellect, and offspring or honor
(or whichever wording they used). If man exists in order to maintain his
life, he needs to own property. As God states, “And the earth He [God]
laid [out] for the creatures. Therein are fruit and palm trees having sheaths
[of dates] and grain having husks and scented plants” (Qur’an 55:10–12).
God created earth with abundant benefits for man, and the first notion of
ownership was ownership of the land that a person revives with his own
hands. Therefore, it is natural that the higher objective of wealth would
come after the higher objective of life in terms of order and priority.
Similarly, it is natural to care about the higher objective of the intellect of the human because intellect is what distinguishes humans from
animals. Of course, the discrepancy here is in the means and not in the
fundamentals themselves. I believe all religions agree on the need to protect and preserve the intellect. Our Islamic literature tells us this is a point
agreed upon by all sects and religions.
The preservation of offspring or lineage is also important. A person’s
lineage requires certain conditions such as having parents: a father and a
mother. The new ethics — or allow me to say the new “nonethics” — wants
to cancel the concept of motherhood and fatherhood, which is part of a
human’s natural disposition (fitrah). In my opinion, I do not see anything
new. I see that the novelty happens in the details and not in the tenets or
the foundations (usūl). This is true even in medicine. The etymology of
the Arabic word for medicine, tibb, means that which treats man. Getting
to know the context through the language points us to the general concept
that everything that treats man is considered medicine.
Regarding the ordering of the higher objectives of Sharia set by the
early scholars, it is important to view this issue as one of kullī mushakkik,
which is defined as a concept that exists in its instances in varying
degrees.1 Such a concept requires verifying the underlying character
(tahqīq al-manāt) at every one of those varying degrees. Independent
1
Editor’s note: As an example, the color green is kullī mushakkik because different objects
exhibit various shades of green. Kullī mushakkik stands in contrast to kullī mutawāṭi’,
which refers to a concept that exists in its instances univocally. For example, humanity is
kullī matawāṭi’: all humans are equal in their humanity.
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legal reasoning (ijtihād) requires tahqīq al-manāt, which means the application of agreed-upon rules on a foreign reality. In other words, the rules
and values are well established, but the question is: what is the relationship of these rules and values to reality? This is a key challenge facing us
today. Industrial capitalism has occluded the prospect of practicing tahqīq
al-manāt. Modern man’s greed, his rush to gain money even at the detriment of others, and his lack of care and devotion to serving others sometimes means that he is indifferent to and careless about morality. This
triggers the set of problems raised by Dr. Al-Bar earlier.
I am fond of tahqīq al-manāt because it is my specialty and it is an
area I am currently working on. If I may, please allow me a bit of digression. Here is a question: Is the president of a country considered a caliph?
Or is he the guardian of a constitutional document, while a caliph was
considered the guardian of both worldly life and of religion. I believe the
latter is true, so questions arise about how to apply religious legislations
to the realities of our modern life. What benefits and harms result from
answering these questions in one way versus another? In the case of Egypt
today, should priority go to society’s safety and security or to the implementation of some religious rulings? I would say that the safety and security of society is the first higher objective of Sharia. Likewise, do we still
have the same understanding of men being the protectors and maintainers
of women? Is the working woman expected to singlehandedly provide
care to her child, or does the man now have a large part in childcare?
These questions need answers because of the new realities of our time.
Similarly, is the idea of the abode of Islam (dār al-Islām) and the abode
of non-Islam (dār al-kufr) still applicable today? Today, it is all considered one land. International relations have changed, international treaties
and agreements are different, and the nature of war has changed. All of
these issues present confusion, and we need to become like the mujtahid
who exerts his or her utmost effort to arrive at a certain truth or what is
close to it.
Mohammed Ghaly
So is the ordering [of the higher objectives of Sharia] based on independent legal reasoning (ijtihād), or is it fixed and unchanging?
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Abdullah Bin Bayyah
The order of principles is based on independent legal reasoning (ijtihād),
and it depends on a group of the governing texts and the comprehensive
juristic rules (al-qawā‘id al-kullīyah). This means if you want to develop
a higher objective, you have to look at the Sharia rulings that affirm it.
As stated in a verse, “…And whoever denies the faith — his work has
become worthless…” (Qur’an 5:5). So you must search for relevant texts
that are certain and governing in order to decide on the higher objective.
In other words, it is open for independent legal reasoning but this does not
mean it can be arbitrarily decided; there is a system.
Ahmed Raissouni
We are now talking about the ordering of the five necessary higher objectives (darūrīyāt) specifically and not about the ordering of all of the
higher objectives of Sharia. The order of the five necessary objectives is
of course an intellectual and rational endeavor, an example of independent
legal reasoning. In fact, the specification of the five necessary objectives
and their naming are based on human thought and reasoning formulated
over a period of three or four centuries, and the efforts continue. The role
of independent legal reasoning is clear, but independent legal reasoning
is of course done using proof. So if scholars provide the textual evidence
and valid reasoning, then this independent legal reasoning is binding just
like it is in any other case, unless and until it is refuted by evidence — and
nothing refutes this ordering.
However, the most important thing is the idea of ordering in the first
place. Then comes the ordering that I mentioned, at least the three levels
that are agreed upon by all who have addressed the issue of ordering.
This is one aspect. A second aspect is that there is another ordering that
has an effect on this issue. This other ordering has to do with the division
of benefits (maṣāliḥ) respectively into necessities (darūrīyāt), needs
(hājīyāt), and luxuries (tahsīnīyāt). It is interesting to note that we find
certain behaviors, actions, and rulings that can sometimes be classified
as necessities and other times as needs. Even food itself is an example.
The default category food belongs to is that of necessities. However,
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in some instances food can be considered among needs and in other
instances it can be considered among luxuries depending on one’s context, for example.
The order here is agreed upon, that the necessities (darūrīyāt) are
above the needs (hājīyāt), which are above the luxuries (tahsīnīyāt). This
is in the form of a theoretical organizing table, but when we engage with
reality, the process of application — or tahqīq al-manāt as Sheikh Bin
Bayyah calls it — requires precise considerations in every single case.
As Sayf Al-Din Al-Amidi says, we might find what appears to be the
preferring of the preservation of wealth over the preservation of religion.
In other words, we may find a case where we prefer what is usually
ordered lower over what is usually ordered higher. However, these are
specific applications. A person, for the sake of his wealth, is exempted
from performing hajj, which is a pillar of Islam. He is exempted from congregational prayer if he fears for his wealth. He is exempted from fasting
if he fears for his health. These are specific applications that require
going back to the categories of necessities, needs, and luxuries. In all
cases, a need has never been given preference over a necessity, and a
luxury has never been given preference over a need or necessity. This is
what I would say generally on the topic of ordering.
I would also like to comment on Dr. Beauchamp’s point about applying the four principles together, as a set. I would agree and I would say the
same about both the set of four principles and the set of five necessary
objectives: within each set, the elements are all equally important. This is
because the necessary objectives of Sharia, as a whole group, are that
without which life is unsustainable. By definition, if one necessity ceases,
life itself ceases. If religion ceases, people become barbaric and harm each
other. Even wealth, which is usually given a low priority in the ordering,
is important because without it, crops would perish and people would die.
There was a discussion about the events currently taking place in
Mali. Some of my colleagues said that self-determination is the solution
for Northern Mali, while others said that we should not accept the division of Muslims. The answer was that the division of Muslims was happening anyway, so the priority should be to stop the bloodshed. Any kind
of unity between the North and South would entail either fighting or selfdetermination. My point is that verifying the underlying character of
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Script of Oral Discussions (Day 2, Session 3) 197
certain issues (tahqīq al-manāt) has its own calculations and its own
vision as to how to fulfill a need.
Also, I will make a brief comment regarding the definition of medicine and changes in medicine, and I would like to hear others’ opinions on
this, especially Dr. Beauchamp. I believe the reality of medicine today has
expanded beyond its previously known limits. Does this expansion mean
that there is a new understanding of medicine, from the perspective of the
World Health Organization, for example, or from the perspective of any
other party? Has a new understanding emerged that includes mercy killing,
abortion, and the torture of prisoners? Yes, military doctors now participate in the torture of prisoners, whether military or civilian. These are all
new unethical and criminal roles practiced by doctors. Does the definition
of medicine encompass this, or is this something else forcibly attributed
to medicine? Is there a new definition of medicine other than the one
mentioned by Dr. Al-Bar, which is preserving health and warding off
harm? That, or something similar, has been the definition for a long time.
However, nowadays there are widespread medical practices that are not
encompassed by that definition whatsoever. An example is plastic surgery.
We heard about the scandal that happened a few months ago in France
regarding the artificial body parts that led to cancer. Plastic surgery has
started to contribute to deformations, lesions, and impairments while this
is not from the core of the medical field. It is not one of the roles of the
doctor to beautify a man or a woman; instead, a doctor is responsible for
treating illness and preserving health. Do we have a new understanding of
medicine that goes beyond our traditional understanding?
Tom Beauchamp
I think we are in a period in which we are attempting to rethink the doctor–
patient relationship and all the functions of the physician. Just think
about the people being produced by medical schools and then what people
can do when they come out of medical schools. They can be involved in
public health, they can be involved in the medical humanities, or they can
be involved in the basic sciences among other things. They may have no
contact with patients whatsoever, or they might have 100 percent contact
with patients. Doctors can do a lot of things, and [their role] is going to
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change even more dramatically. People who are trained to be physicians
are going to be able to do a great deal more in terms of diversity than they
were in the past and will continue to adjust the system to their being able
to do that. Probably some of these things will be good, and probably some
of them will be bad.
That is part of where ethics comes into the situation. For example, we
now have many more conflicts of interest than we have ever historically
had in medicine. The biggest one historically was of course fee-forservice that led to certain kinds of problems. How are we going to handle
these problems arising from conflict of interest? It is the same point
I made earlier: as we expand the number of things that physicians and
people involved in the healthcare system can do for people and the things
that can go wrong ethically, we will need new ways of regulating that and
controlling it and so on.
Tariq Ramadan
I have a question for Sheikh Bin Bayyah. You said that the foundations of
religion (uṣūl) do not change and rather the issue is about verifying the
underlying ground (tahqīq al-manāt) and applying those foundations in
the context (tanzīl). Dr. Beauchamp said something else. He said that the
changes in medicine now spurred them to come up with four principles
that are derived from reality, from the changes in medicine and from
changes in the doctor–patient relationship. This brings me to the issue
raised by Sheikh Al-Qaradaghi regarding the preservation of society. The
security of society is a new concept and is very important. So there is a
change here in the foundation, and it is possible sometimes that the ordering would change. So is this possible? Or do we have to go back to the
tradition of what the earlier Muslim scholars, and would that be enough
as a response? We have to realize that it is no longer only about the doctor–patient relationship. Rather, it is about the preservation of the safety
of society.
Jasser Auda
I would like to add to this last question regarding the fact that objectives
have to do with the individual. I mean they are intended to preserve the
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Script of Oral Discussions (Day 2, Session 3) 199
life of the individual, the mind of the individual, the honor of the
individual, etc. Dr. Ramadan, on the other hand, spoke about society and
that the old ethics relevant to individuals can no longer cater for the needs
of society. So if, in the science of the higher objectives of Sharia, we were
discussing the life of the individual and the honor of the individual, etc.,
now at the societal level things become more complicated when we discuss the “life” of the society or the “honor” of the society. My question is
about the social or societal dimension of the higher objectives of Sharia:
Does it affect or put pressure on the theory [of higher objectives]? Is there
a need to change the theory to become a theory for the society instead of
a theory for the individual, which is what it has historically been?
Ali Al-Qaradaghi
As I explained earlier, the safety of society and the safety of the state have
been given two criteria [individual and communal] in Islamic law
(Sharia). These two criteria are not entirely encompassed by concept of
the higher objectives of Sharia because the Islamic legal jurists (fuqahā’),
may God reward them greatly, focused on the individual because the individual is the basic unit [of society]. However, reality dictates that safety is
the safety of society, and it includes political, economic, societal, and
environmental security. I will not elaborate on these issues now but rather
will talk about what the scholars of legal theory (uṣūl) have contributed
on the matter.
As Sheikh Raissouni said, the higher objectives of Sharia are a topic
that has been discussed for several centuries, starting with Imam
Al-Haramayn and continuing into the present day. We are all trying to
understand it. For example, in my opinion, the order of the higher objectives is based on independent legal reasoning (ijtihād) which is not conclusive in nature. In other words, the order is based on independent legal
reasoning that is open to discussion and revision, but it remains a sort of
a general principle. For example, we all say that religion is prioritized
above life. If we specify “religion” to mean the religion of the individual,
when an individual’s religion threatens his life, then in that situation, it is
accepted that life is prioritized over religion, as long as he is in his heart
still steadfast on the truth. However, if we specify “religion” to mean the
religion of the society, when religion in total is jeopardized, this is where
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we would say that religion is indeed prioritized over life. In this case
there would be jihād within its proper limits or norms, and jihād is not
defined as the killing of the soul for just any reason. Therefore, it is
incredibly important that we look at the issue at the individual level and
the societal level.
Here are some more examples: whoever is killed defending his wealth
is considered a martyr; whoever is killed defending his honor (‘ird) is
considered a martyr; and whoever is killed defending his soul is considered a martyr. These cases indicate that the prioritization can change
depending on the situation. In my opinion, we need to work more on this
issue. The matter requires the establishment of groundwork and standards
because so far we can only talk about generalities: in general, religion is
prioritized over life, for example.
What I mean by “religion” here is not Islam in its entirety because the
preservation of life, honor, and wealth are all a part of Islam. By religion
I mean specifically the aspects of Islam relating to ritual worship and the
like. The higher objectives of Sharia are not evidence by themselves,
standing alone. I cannot come to a conclusion where my only evidence is
the higher objectives. The higher objectives of Sharia serve as standards
and criteria (mi‘yārīyah): they are only a scale by which to weigh evidences against each other. They are part of Islam and cannot function as
independent evidence by themselves.
Abdullah Bin Bayyah
To be honest, I am afraid that we will end up in what is called a Byzantine
discussion. Reality is not always what we see. “And you see the mountains, thinking them rigid, while they will pass as the passing of clouds.
[It is] the work of God, who perfected all things…” (Qur’an 27:88). What
we see could be misleading. Since the beginning of humanity’s existence,
humans have had needs like wealth. I do not agree that the legal jurists
focused exclusively on individual issues [when it comes to the higher
purposes of Sharia]. Rather, when we say preservation of “individual”
life, we also mean the preservation of the society and its safety. Indeed, if
the need is a public one, then it is emphasized as such. It is as Al-Ghazali
said and also as stated in Al-hāshīyāt: a certain need is either a public one
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Script of Oral Discussions (Day 2, Session 3) 201
or an individual one. So I urge us to not jump to conclusions about what
the early scholars said.
If we say that religion came to preserve for people both their worldly
benefit and their benefit in the Hereafter, this demonstrates the centrality
of religion as a higher objective since the loss of the Hereafter is a great
loss, at least in the eyes of the believer. In my opinion, the changes happening around us are immense, but the basic needs of humans will stay for
as long as humans walk the Earth. No doubt man needs to eat, to be
clothed, to live, to die, etc. These needs do not change. If they change, all
rulings change. If these basic human needs do not change, then the higher
objectives of Sharia [still apply].
The higher objectives of Sharia provide a broad framework, and they
are indeed “high” and thus do not produce rulings directly. Under them is
a set of other objectives that come second to the higher ones but not necessarily secondary to them, and so on. For example, justice is considered a
kullī mushakkik (a comprehensive concept comprising instances of varying degrees). Al-Shatibi said there are 70 degrees of justice, ranging from
obligatory on one end to recommended to permissible on the other end.
Similarly, the objectives of Sharia exist in levels or degrees. Nevertheless,
one thing is clear. There do exist high objectives that apply to society in
general and not only to individuals. Take the verse, “And there is for you
in legal retribution [saving of] life, O you [people] of understanding, that
you may become righteous” (Qur’an 2:179). Life for whom? The murderer’s victim has died. Life here refers to the life of the society.
Muhammad Ali Al-Bar
Dr. Beauchamp said that before the 1970s, there was a different reality
and thus they were obliged to come up with the four principles. In 1964,
there was the Declaration of Helsinki and before that as well there were
a number of similar efforts. The Declaration of Helsinki talked about a
host of ethical principles including those associated with defining risks,
how to protect the rights of participants of scientific experiments, the
responsibilities of the doctor in preserving the life of patients, the importance of upholding scientific research standards, respecting the environment, and proper treatment of animals. It also discussed the need to
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provide a protocol to the Institutional Review Board; the importance of
being transparent about the ethical issues involved in a scientific research
project; disclosing all associated risks; conducting research only on individuals who are suited for such research; taking the voluntary permission
of research participants after disclosing all relevant information; the
need to get patient consent detailing the different types of consents,
withdrawals, refusals, or participations; and more. The detailing of all
these points did not start in the 1970s; rather, it was declared on an international scale with the Declaration of Helsinki in the year 1964, and other
similar things did also exist.
Tom Beauchamp
I will comment briefly and then we can discuss. First of all I did not say
the 1970s. I specifically said the 1960s was when I think the big change
was made, and I mentioned the dialysis case. The dialysis case appeared
1 or 2 years before the Declaration of Helsinki. This was clearly a very
instrumental period in the change. What is important to understand, and
what I was emphasizing before, is why we had to have this change. Why
it is a radical change to have something like the Declaration of Helsinki,
which really is not a very good document. It was an early, rather poorly
constructed document. It is very different today, but it was quite poorly
constructed in the 1960s. The main point here is why we needed it. We
needed it because we had nothing. We had nothing to cover that area
whatsoever. That is the really important point.
Now let us step back a minute because someone earlier mentioned the
Nuremberg trials. The Nuremberg trials are a fabulous example of how we
missed the boat because we did not understand the need for change that
we had. The Nuremberg trials were an American military tribunal. It was
originally set up to be four different countries that would try the tribunals,
but ultimately it became an American military tribunal. In the end, in my
view, it was an absolute disaster. The trials did bring forward a lot of evidence, and the evidence was in many respects very carefully monitored.
Some of the judges exhibited some good reasoning, but the truth of the
matter is that it was a kind of mockery. Why? Because the American
military at the time found guilty German physicians who were doing
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Script of Oral Discussions (Day 2, Session 3) 203
exactly what the American military was doing at the time. Now, what did
we learn from German experimentation about what was lacking in our
system? The answer is nothing.
It is often said that the Nuremberg trials were a great precedent and
the Nuremberg Code is a great precedent. Historically, that is just very
false. What happened in Germany in 1946 and 1947 was a finding of
guilt — or innocence in some cases — of a group of German physicians,
and then we walked away from it. I want to emphasize that we walked
away from it. I want to emphasize it was not just the Americans who
walked away from it. In my view, disgracefully, it was the whole world
who walked away from it. No one took Nuremberg seriously. The
Germans, at that time it was East Germany and West Germany, both
rejected it wholly and completely. They took nothing away from it. The
Americans, who had conducted the trials and had come up with the socalled Nuremberg Code, did not institute one single principle of that code
anywhere in the culture or the government or anywhere else; nor did any
other country. It was a huge lost opportunity. It was difficult to come to
grips with the fact that we had no system to control science of the sort
that had gotten out of control and, actually, was out of control in the
United States at the same time.
I say you not only were having changes, you needed these changes,
and we missed the boat. I think we bear — maybe the American military
more than anybody else — we certainly bear as a culture in the United
States and I think the world bears some guilt here for failing to understand
because we went on with this kind of experimentation well beyond the
Declaration of Helsinki. It went on and on for another 30 or 40 years during which a great many experimental subjects were being abused because
we did not have anything put in place to control it. To be precise about
this, in the case of the United States, it was not until roughly 1968 that we
had any controls whatsoever put in place, and those were for entirely different reasons. They had nothing to do with the Declaration of Helsinki
and nothing to do with the Nuremberg trials. They had to do with certain
legal problems in the American system where we were concerned about
the liability of the national institutes of health. So when I say there were
dramatic changes in the 1960s and then again on the biomedical ethics
side of it in the 1970s, I believe that that is entirely accurate and true.
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People continue to praise the Nuremberg Code and its impact. There was
nothing to be praised in the Nuremberg Code and its impact because there
basically was no impact. I could go on and on about that and about the
Declaration of Helsinki. The Declaration of Helsinki is nowadays being
rejected more than it is being accepted, but that is a different story.
Annelien Bredenoord
I would like to ask you a question about what you call specification. In the
end, the principles are abstract moral norms. In order for them to be an
action guide or to be used for what we call applied ethics, they need to be
specified to concrete cases. In the end, it could be very well possible that
with different concrete specifications, there is pluralism at the level of
specification. In other words, there could be several existing specifications that conflict with each other and that collide with each other. So
when can you say that one specific specification is more justified than
another specification?
You also say that a specification is justified if it is consistent and
coherent: consistent with common morality and coherent within its own
system. I think you can check whether it is coherent with its own system,
but how can you check whether a specification is consistent with the
norms of common morality because then you have to be quite lucid about
what entails common morality. Perhaps you can elaborate on that.
Tom Beauchamp
There are lots of problems here. One is that we do not have as good an
understanding of the common morality as a whole as we would like to
have. I understand your question to be not about medical or biomedical
ethics in particular but rather about the general problem of how to hold the
whole thing together and know that one set of specifications is better than
another.
There is a basic rule that I operate with, and Childress and I tried to
spell it out to some length, although probably not a satisfactory length,
but the idea is quite simple. Any set of specifications that is coherent
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Script of Oral Discussions (Day 2, Session 3) 205
with the general principles of the common morality — whatever those
principles exactly turn out to be — if it is coherent both internally with
itself and also coherent with the principles of the common morality, then
it is acceptable. That can lead to many different, to take my example
earlier, professional guidelines. There are many different professional
guidelines, and each professional association may have a somewhat
different one. To answer your question, yes, they can conflict with one
another — there is no doubt about it. I think it is just a matter of fact that
that is the case, and they justifiably conflict. The way I want to take that
up is: everything is justified if it is coherent with common morality until
the point at which it violates a principle of the common morality, in
which case it is obviously no longer coherent. That is where I think
problems begin.
So if you go back to what we were discussing a minute ago, the
German experimentation and American experimentation in the 1930s or
principally in the 1940s, they stepped over the line. They clearly stepped
over the line and were violating those principles. So if you had tried to
specify a moral system to govern what was being done (there actually
were some attempts at the time to do that by the Department of Defense
in the United States), they would have been over the line. In other words,
they would not have what I would call a system of biomedical ethics that
is coherent with the common morality. That is the basic answer to your
question.
It is terribly complicated in part because we also do not have an
adequate theory of coherence, a philosophical coherence theory. We have
lots of them, but we still do not have an adequate account that engages in
this area that we are talking about, which is applied ethics. That is, so to
speak, still to be written.
Tariq Ramadan
Professor Beauchamp, I have one clarification about the terminology that
we are using. We talked about medicine, we talked about bioethics, and
while I was listening to you right now you used the term biomedical
ethics. What is the difference between medicine and biomedicine?
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Tom Beauchamp
I have never liked the word bioethics, and that is just a personal preference. It does not mean very much to me to abbreviate it. The word was
adopted in the very late 1960s probably by two separate people, but I will
not go into that history. It was a very shorthand way of attempting to get
not only what we think of as biomedical ethics but also bioethics more
broadly as when we speak today about something like biodiversity, so it
incorporated an environmental ethics. I have always thought that the term
bioethics was too unclear. Childress and I did not want to use it and so we
put biomedical ethics in the title of our book. However, having said that,
that is more a personal preference on my part than the way usage is actually developed. Usage today is such that, universally, the word bioethics
is used far more than biomedical and it has become the standard word.
To make this really simple, they are synonymous. I think nowadays they
have become synonymous so biomedical ethics is bioethics, and there is
no difference between them even though someone like me would like to
draw a difference between them.
Mohammed Ghaly
I have one final question about the beginning of the story of writing your
book in the 1970s. When you were sitting in your office together with
Dr. Childress, how many ethical principles did you and Professor
Childress have on the table before you arrived at the four principles? In
other words, I am sure you had a list of possible principles and you had
to choose some. How many did you originally have?
Tom Beauchamp
That is a historically interesting question and a little bit hard to unravel.
You are asking a historical question about what happened. Two things
were taking place. Childress and I were lecturing in a course for health
professionals, and we were not using the language of principles — or
rather, the language of principles was, so to speak, secondary. We were
principally lecturing on ethical theories, and so then we would talk about
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Script of Oral Discussions (Day 2, Session 3) 207
the principles that can be justified in light of the ethical theories. At the
same time as I was doing this, I went on the staff of the National
Commission for the Protection of Human Subjects of Biomedical and
Behavioral Research, where I wrote the Belmont Report for that National
Commission.
So I was writing the Belmont Report at the same time Childress and
I were lecturing in this course. After each lecture, Childress and I would
sit down and try to figure out what we were learning from one another
through our lectures as well as what I was learning at the National Commission. The National Commission, as you probably know, in the Belmont
Report uses three categories: respect for persons, beneficence, and justice.
I was not happy with the way in which they were using the language of
respect for persons, and I was not happy with the way they were using the
language of beneficence.
The biggest part of the early discussions that Childress and I had,
although we already had those principles on the table, was exactly how we
wanted to fashion the principles. So we decided to throw out the principle
of respect for persons. There were a number of reasons for that. One, we
simply thought it was far too confusing in the literature of what a person
is. By the way, I believe that continues to be the case today. We did not
think it is a manageable principle to develop along those lines. We also
thought that when you are talking about first priorities, it was basically
respect for autonomy, so that became the principle. Beneficence we
thought was highly confused by the National Commission because it
threw beneficence and nonmaleficence together into one principle. We
decided that you had to break that out, and so we broke it out. Justice
we thought was far too narrow as it was conceived by the National
Commission because it basically had to do with the selection of subjects
for research. We thought justice had to be considerably generalized, so we
began to think about the scope of that principle.
It was in a context in which those were the principal things that were
on the table that we eventually ended up with the basic understanding.
It is the four folds concept when you think about it, so you have concepts
like the concept of nonmaleficence and the concept of autonomy. You then
fashion the principle around the concept, then you refine the principle to
try to get it just right. That is the process we used.
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Now you might have been asking if there were other principles on
the table. We certainly looked at a lot, but we were never very attracted to
any. I will give you a couple of examples. There were virtually no books
at the time we started that discussed principles of medical ethics or biomedical ethics or whatever. The most plausible books or articles for that
matter were old. I mean by this several years old treaties on principles in
the Roman Catholic tradition. The Roman Catholic tradition has always
been keen on developing principles. However, those were far too narrow
and specific to the Roman Catholic religion, especially for what we
wanted to do, which was basically a secular bioethics, as you know, that
cut across all traditions. So we found that nothing in that tradition in the
way of principles was going to help us. Another thing that of course was
very much discussed at the time was the principle of utility. We decided
that the principle of utility was simply unacceptable as a general principle
and had to be folded under the principle of beneficence. So we went
through a process of thinking like that, and that is how we ended up with
what we have now.
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Part III
Islamic Perspectives
on the Principles
of Biomedical Ethics
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Islamic Perspectives on the Principles of Biomedical Ethics
Ethics in Medicine:
A Principle-Based Approach
in Light of the Higher
Objectives (Maqāṣid) of Sharia
Ahmed Raissouni
Abstract: The main premise of this chapter is that ethics is an indivisible
whole and thus cannot be divided into various segments, each of which
may fit within a specific aspect of life such as medicine, politics, finance,
or social relations. However, specific principles and values can be more
highlighted in particular fields because they will work more efficiently
and be more productive than other clusters of values and principles. This
chapter is divided into two main sections. The first section elaborates on the
position of ethics in Sharia and its higher objectives arguing that life in its
totality must be based on ethics. The second section focuses on ethics in the
field of medicine arguing that the medical field in particular cannot survive
unless it is based on ethics. Two main virtues are highlighted in this chapter
because of their relevance to the field of medicine, both of which constitute
two major principles of Islamic ethics as well, to wit, God-consciousness
(taqwá) and mercy (rahmah). The chapter also touches upon the overlap
between the higher objectives of Sharia and those of medicine. The main
211
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objectives of Sharia are protecting (hifz) the so-called five necessities,
namely religion, life, offspring, intellect, and wealth. Three of these five
represent the main objectives of medicine, viz., protecting life, offspring,
and intellect.
1. The Status of Ethics in Light of Sharia
and its Higher Objectives
The high status conferred upon ethics in Islamic Sharia is evidenced
through the following aspects:
1.1. Ethics (akhlāq) and Creed (‘aqīdah) Form
the Basis of Sharia
This first aspect is particularly discernible for those who reflect on the
Qur’anic verses revealed in Mecca. The majority of these verses, as is
well known, establish creed and morality as the foundations of the message brought forth by the Prophet Muhammad (PBUH) and of Islamic
Sharia. These foundations were named “all-inclusive rules” (al-qawā‘id
al-kullīyah) by Imam Al-Shatibi. This category of rules encompasses
Islamic creed and Islamic ethics. Al-Shatibi, may God have mercy upon
him, states,
Know that the “all-inclusive rules” were the first decrees … and the
foremost of these decrees was belief in God, His Messenger, and the
Last Day. These were followed by general principles such as ritual
prayer, charity, etc.1 Subsequently came the forbiddance of disbelief
and any practices associated with it, such as engaging in animal slaughter in favor of falsely claimed deities or any parties other than God or
enjoining upon themselves unfounded prohibitions and permissions, all
of which contradict the principle of worshipping God alone. In addition, all good morals were enjoined, including justice, beneficence,
1
These commands were mentioned in the portions of the Qur’an revealed in Mecca in a
general form, without details about application. For this reason, Al-Shatibi considered
them to be among the comprehensive principles (kullīyāt) and basic fundamentals (usūl
asāsīyah).
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Ethics in Medicine 213
keeping promises, forgiveness, avoiding ignorance, repaying evil with
benevolence, fearing only God, patience, gratitude, and others. Concurrently, immoral behavior was prohibited, including vice, maleficence, oppression, speaking without knowledge, engaging in fraud and
duplicity, corruption, adultery, murder, infanticide, and several other
transgressions that were common prior to the advent of Islam…2
In his exegesis of the verse revealed in Mecca, “He has ordained for
you of religion what He enjoined upon Noah and that which We have
revealed to you, [O Muhammad], and what We enjoined upon Abraham
and Moses and Jesus — to establish the religion and not be divided
therein…” (Qur’an 42:13), the judge Abu Bakr bin Al-‘Arabi explained,
It means that God ordained the same religion to both Muhammad and
Noah, namely in the principles that both religions advocate: the belief in
God as the only God, ritual prayer, almsgiving (zakāt), fasting, pilgrimage (hajj), getting closer to God by observing righteous deeds, seeking
closeness to Him by what gets the heart and body organs focused on
Him, truthfulness, fulfilling promises, restoring trusts to their owners,
maintaining kinship relations, and forbidding: disbelief, murder, harming people, attacking animals in any way, committing obscenities, and
engaging in violations of honor.3
It is worth noting that if we were to restrict ourselves only to the moral
commandments and prohibitions conveyed through the early Qur’anic
verses during the founding stages of the message of Islam, as highlighted
by Al-Shatibi and Ibn Al-‘Arabi, this would encompass the following:
Commandments: justice, beneficence, maintaining ties of kinship,
keeping promises, honoring trusts, forgiveness, avoiding ignorance,
repaying evil with benevolence, fearing only God, patience, gratitude,
honesty, and seeking closeness to God through all good deeds.
Prohibitions: vice, maleficence, oppression, speaking without knowledge, engaging in fraud and duplicity, corruption, adultery, murder,
2
Al-Shatibi (1997). Al-muwāfaqāt fī usūl al-sharī‘ah, Cairo: Dar Ibn ‘Affan: vol. 3, 335.
Al-Qadi Abu Bakr bin Al-‘Arabi (2003). Rulings of the Qur’an (Ahkām al-Qur’ān),
Beirut: Dar al-Kutub al-‘Ilmiyah: vol. 4, 89–90.
3
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infanticide, harming others, assaulting animals, committing obscenities,
and violating honor.
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1.2. Abundant Texts and Expansive Ethical Discussions
Ethical concepts and directives were not exclusive to the initial Qur’anic
verses revealed in Mecca. Rather, they were expanded upon and reiterated
across diverse Sharia texts and at all levels. An exploration of thematic
classifications within the contents of the Qur’anic verses and Prophetic
traditions clearly highlights the abundance, if not being the most abundant, of those themes and directives of a moral nature.
Perhaps the strongest evidence of the expansive space afforded to
ethics in Islam is represented through the creation of a multivolume encyclopedia on ethics and morals under the supervision of Dr. Saleh bin
Humayd and Mr. Abdul-Rahman bin Mulawwih. This encyclopedia was
published in 11 volumes and was titled Mawsu‘at nadrat al-na‘īm fī
makārim akhlāq al-rasūl al-karīm. It addressed 342 of the ethical and
moral qualities included in the Qur’an and Prophetic Tradition (Sunna),
encompassing internal and external (intrapersonal and interpersonal) ethics across all areas of public and private life. A thorough examination of
the encyclopedia’s index of topics explicitly reveals the high status of
ethics in Islam, in addition to the pervasiveness and frequent occurrence
of ethical directives across Qur’anic verses and Prophetic narrations.
1.3. The Harmony between Ethics and Religion
In a verse in which He is addressing the Prophet Muhammad — peace and
blessings of God be upon him (PBUH) — God the Almighty says, “And
indeed, you are of a great moral character” (Qur’an 68:4). The majority
of Qur’an interpreters consider the great moral character of the Prophet
(PBUH) to be the comprehensive representation of Islam and all Qur’anic
teachings. In other words, the summation of Islam and the Qur’an in their
entirety is represented through great moral character. The Prophet’s wife
‘A’ishah, may God be pleased with her, elaborated on this concept to
those Companions who had asked her about the Prophet’s character in
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reference to the above-mentioned verse; she replied, “His character was
an embodiment of the Qur’an.”4
Imam Al-Tabari says,
The interpretation of God the Almighty’s saying, “And indeed, you are
of a great moral character” (Qur’an 68:4) is that God the Almighty says
to His Prophet Muhammad, may the peace and blessings of God be upon
him, that indeed, O Muhammad, you are of great manners, manners
which constitute the manners of the Qur’an which God has inculcated
into you and which are Islam and its legislations. The Qur’an interpreters said something similar to this explanation.5
Ibn ‘Ashur said, “We have learned for sure that Islam is perfecting
good morals and that the entire set of good morals boils down to Godconsciousness (taqwá).”6
Accordingly, several scholars stated that, “Morality pervades religion;
therefore, whoever exhibits better manners than you is superior to you in
religious commitment.”7 Hence, the standard by which one’s religiosity is
measured is exemplary moral behavior, meaning that a person who practices good manners is considered righteous and vice versa.
Al-Bayhaqi reported through his chain of narrators on the authority
of Ka‘b bin Malik, may God be pleased with him, that a man from Banu
Salamah relayed to him that he had asked the Messenger of God (PBUH)
about Islam. The Messenger of God (PBUH) replied, “It is good manners.” The man repeated the question, and the Messenger of God (PBUH)
once again responded, “It is good manners,” until he had repeated it
five times.8
4
Narrated by Ahmad in Al-Musnad, No. 24601 on the authority of ‘A’ishah. It was also
narrated by Muslim in Salāt al-musāfirīn wa-qasrihā, No. 746 in the following words:
“Indeed, the character of the Prophet of Allah (PBUH) was the Qur’an.” It was also
narrated by Abu Dawud in Qiyām al-layl, no. 1342 and Al-Nasa’i in Al-Salāh, No. 424.
5
Al-Tabari (2000). Jāmi‘al-bayān, Beirut: Mu’assasat al-Risala, vol. 23, 528.
6
Ibn ‘Ashur (2001). Usūl al-nizām al-ijtimā‘ī fī al-Islām. Jordan: Dar Al-Nafa’is: 207.
7
Al-Firuzabadi (1996). Basā’ir dhawī al-tamyīz, Cairo: Al-Majlis Al-A’la li al-Shu’un
al-Islamiyah: vol. 2, 568.
8
Narrated by Al-Bayhaqi in Shu‘ab al-īmān, vol. 6, 242.
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The Prophet (PBUH) clarified that the overarching purpose of his
mission was to perfect noble character, as indicated by his statement,
“I was only sent to perfect noble character (makārim al-akhlāq).”9
1.4. Comprehensive Moral Principles in Islam
Perhaps the most overarching purpose behind the cultivation of ethics
across all divine messages is purification of the soul (tazkiyah). Purification
of the soul involves purging the individual of any internal or external
immorality and the fostering of internal and external virtues. In fact, this
purification is seen as the common ground bringing together all divine
messages. There are numerous Qur’anic verses that clearly refer to purification and edification as important aspirations. For example:
(1) “It is He who has sent among the unlettered a Messenger from themselves reciting to them His verses and purifying them and teaching
them the Book and wisdom…” (Qur’an 62:2).
(2) “Our Lord, and send among them a messenger from themselves who
will recite to them Your verses and teach them the Book and wisdom
and purify them…” (Qur’an 2:129).
(3) “Just as We have sent among you a messenger from yourselves reciting to you Our verses and purifying you and teaching you the Book
and wisdom…” (Qur’an 2:151).
(4) “Certainly did God confer [great] favor upon the believers when He
sent among them a Messenger from themselves, reciting to them
His verses and purifying them and teaching them the Book and
wisdom…” (Qur’an 3:164).
In reference to the Qur’anic verses above, the eminent scholar Abu
Al-Hasan Al-Nadwi, may God have mercy with him, said, “God the
9
Narrated by Al-Bazzar in his Musnad, vol. 15, 364 and by Al-Bayhaqi in Al-Kubrá,
vol. 10, 191, No. 21301 in this wording. It was also narrated by Ahmad in Al-Musnad,
No. 8595; Al-Hakim in Al-Mustadrak, vol. 2, 670; and Al-Bayhaqi in Shu‘ab al-īmān,
vol. 10, 352, all three in the words “righteous manners.” It was also narrated by Malik in
Al-muwatta’, No. 3347 in the words “goodness of manners.”
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Ethics in Medicine 217
Almighty stated the main purposes and benefits of Prophet Muhammad’s
mission in several verses of the Qur’an,” meaning the aforementioned
verses. He then said: “The task of moral discipline and purification of the
soul is highly valued in the Prophet’s calling to Islam (da‘wah) as asserted
by the purposes of his mission.”10
There are multitudes, perhaps hundreds, of psychological and behavioral qualities that constitute the elements of moral purification. Due to
the diversity and interconnectedness of these elements, philosophers and
ethicists attempted to trace them back to a central, governing framework
of comprehensive principles. Thus, they defined four principles of virtue
(which they considered to be the essence of all virtues) and determined
their opposites to be the essence of all immorality. According to Ibn
Miskawayh, “Philosophers unanimously hold that the four categories of
virtue are: wisdom, abstinence (‘iffah), courage, and justice.”11 He then
said, “The opposites of these four are: ignorance, greed, cowardice, and
injustice.”12 Following this, he outlined the various branches of virtues
and vices based on these eight main categories.
Al-Ghazali said, “Although there are multiple virtues, they can be
reduced to four all-inclusive categories: wisdom, courage, abstinence, and
justice. In reasoning, wisdom is the virtue; in anger, courage is the virtue;
in desire, abstinence is the virtue; and justice is the way in which these
elements fall in the appropriate order. Through justice, perfection is
attained in all matters. Hence, it is said that, “The heavens and the earth
are founded on justice.”13
Al-Ghazali went on to elaborate on these four principle virtues
explaining that, “Psychological virtues … include four types: intellect,
which is perfected through knowledge; abstinence, which is perfected
through piety (wara‘); courage, which is perfected through perseverance;
justice, which is perfected through equity. These are verifiably the fundamentals of religion.”14
10
Abu Al-Hasan Al-Nadwi, Al-‘aqīdah wal-‘ibādah wal-sulūk, 134.
Ibn Miskawayh, Tahdhīb al-akhlāq, 19.
12
Ibid., 20.
13
Al-Ghazali, Mīzān al-‘amal, 27.
14
Ibid., 25.
11
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According to the eminent scholar Shah Wali Allah Al-Dahlawi,
happiness can be attained through four channels. Although these channels
may differ in the labels and terminology used by philosophers and ethicists, they nonetheless share similar content and outcomes, particularly
the second, third, and fourth channels. The four channels as identified by
Al-Dahlawi are:
•
•
•
•
Purification;
Devoutness to God;
Tolerance;
Justice.
In his opinion, all Prophets were commissioned by God to preach
these four virtues, and all divine ordinances emerge from these qualities
and serve to delineate them.15
Muhammad Abdullah Draz, author of Moral Code in the Qur’an
(Dustūr al-akhlāq fī al-Qur’ān), argues that, unlike other virtues, Godconsciousness (taqwá) is pervasive across all ethical domains. Hence, it is
the central and foundational virtue in Islamic Sharia whereas all other
virtues and values are single-sided in both content and domain. He asserts,
Traditionally, ethical laws were designated according to their dominant
quality, i.e. individual or collective, spiritual or corporeal, Sharia of justice or Sharia of mercy and so on. However, in my opinion, this onedimensional designation is incompatible within this context. This is
because Islamic Sharia recommends observing justice and mercy
together and emphasizes the complementary harmony between the individual and the collective and the divine and the human. Therefore, if we
were to consider a central virtue in this framework, one foundational
principle that embraces all commandments, the concept of Godconsciousness would suffice. In other words, how else could God-consciousness be expressed other than through a deeply profound respect for
Sharia?16
15
Al-Dahlawi (1999). Ḥujjat Allah al-bālighah. 1st edn. vol. 1: Riyadh: Dar Al-Kawthar:
191–194.
16
Muhammad Abdullah Draz, Dustūr al-akhlāq fī al-Qur’ān: 681.
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Ethics in Medicine 219
This meaning was also emphasized by Ibn ‘Ashur who said, “The
entire set of good morals boils down to God-consciousness.”17
Among the contemporary scholars interested in this topic was Sheikh
Abdurrahman Habannakah Al-Maydani, who wrote a book entitled
Islamic Ethics and Its Foundations (Al-akhlāq al-Islāmīyah wa-ususuhā).
He explored the commendable and prescribed ethical qualities, tracing
them back to their overarching principles. He then examined the different
moral subdivisions under each principle including their immoral opposites. In his description of the nature and outcomes of his work, he
explains, “As I investigated the types of morals utilizing a survey, which
I do not claim to be perfect, and then classified them, I arrived at the following comprehensive principles:
First principle: Loving and Prioritizing Truth
Second principle: Mercy
Third principle: Love
Fourth principle: Social Incentive
Fifth principle: Willpower
Sixth principle: Patience
Seventh principle: Generosity
Eighth principle: High Resolve
Ninth principle: Benevolence
These principles that constitute the fundamentals of moral behavior
have opposites that constitute the fundamentals of vice and immorality.”18
After expending nine chapters in discussing each of these nine principles, the author included a 10th chapter addressing two additional virtues
which he classified as subdivisions under more than one ethical principle;
these virtues are abstinence (as well as its opposite), and courage (and its
opposite).19 It is well known that ethicists consider these two virtues to be
among the four main principles.
17
Ibn ‘Ashur, Usūl al-nizām al-ijtimā‘ī, 207.
Abdulrahman Habannakah Al-Maydani, Al-akhlāq al-Islāmīyah wa-ususuhā, vol. 1, 517.
19
Ibid., vol. 2, 581.
18
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2. Ethics and Medicine
All fields and spheres of life require ethics, particularly as they grow and
advance. The field of medicine is no exception, rather, ethics lie at the
core of the medical profession and they are a necessity for its ongoing
sustainability. Given that Sharia scholars maintain that “morality pervades
religion; therefore, whoever exhibits better manners than you is superior
to you in religious commitment,” it becomes incumbent upon scholars of
medicine to similarly advise one another that “morality pervades medicine; therefore, whoever exhibits better manners than you is superior to
you in medical practice.” Moreover, while the status of a physician may
be determined based on his knowledge, expertise, and skill, his genuine
success is contingent upon his overall moral behavior, including his
conscientiousness, mercy, gentleness, compassion, leniency, patience,
forbearance, and humility.
2.1. Objectives of Sharia and Objectives of Medicine
It is well known that the five objectives of Sharia (maqāsid al-sharī‘ah)
are to protect20 the five necessities: preserving religion (dīn), life (nafs),
offspring (nasl), intellect (‘aql), and wealth (māl).
The objectives of medicine, on the other hand, can be summarized as
the protection of life, offspring, and intellect and thus share three of the
objectives of Sharia. However, it must be noted that the protection of these
three shared objectives also serve in the protection of religion and wealth.
Hence, the objectives of medicine are included in and closely associated
with the objectives of Sharia. It goes without saying that the protection of
life, whether in Sharia or in medicine, is not limited to physical protection.
Rather, protection of life also includes maintaining a safe, healthy, and
balanced psychological state. Sharia then takes this a step further and,
20
Preserving the necessities and other benefits is not limited, as some believe, to maintaining and protecting what already exists of those necessities and benefits, which the scholars
call “preserving the nonexistent” (al-hifz al-‘adamī). Instead, preserving the necessities
first entails seeking to establish the necessities, foster them, and provide all the means
leading to their establishment, which the scholars call “preserving the existent” (al-hifẓ
al-wujūdī). Any type of preservation has two aspects relating first to what is existent and
second to what is non-existent.
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Ethics in Medicine 221
almost exclusively, advocates the preservation of spiritual well-being.
This is perhaps the reason behind many Muslim scholars asserting that
“Sharia is the greatest phyisician.”21
What remains paramount is that the “human being” is the focal point
for both the objectives of Sharia and those of medicine with the purpose
of both being the preservation of people’s physical, psychological, and
mental well-being in their pursuit of happiness. The mission of medicine
is to heal and spread mercy, while religion’s mission is a more comprehensive healing and more expansive mercy. In the Qur’an, God proclaims,
“And We send down of the Qur’an that which is healing and mercy for the
believers…” (Qur’an 17:82). Thus, healing and mercy are the two objectives at which the missions of medicine and Sharia intersect, despite the
differing scopes covered by each.
Sharia scholars summarize the objectives and necessities of Sharia
with two concise expressions, namely preserving religion and preserving
life. In other words, safeguarding the interests of people is contingent
upon the preservation of their religion and their lives. Similarly, happiness
in this world and in the afterlife is founded on the preservation of people’s
religion and lives, and the preservation of both these aspects is considered
to be the pillars of cultures and civilizations. In fact, the basis of any form
of development and progress is the preservation of life and religion.
Interpreters of the Qur’an frequently highlight the significance of the
Qur’anic verse, “It is He who shows you His signs and sends down to you
from the sky, provision. But none will remember except he who turns
back [in repentance]” (Qur’an 40:13). This verse establishes a connection
between the revelation of signs and miracles alluding to God and His messengers on the one hand and gratitude for the divine blessing of His provision of sustenance from the sky on the other hand. Scholars explain that
the implication behind this connection is that these two elements form the
overarching objectives of Sharia, where one refers to preserving religion
(revealing signs and miracles) and the other refers to preserving life (providing sustenance).
Al-Fakhr Al-Razi stated, “Know that the most significant of duties is
protecting the interests of religion and the interests of life. God the
21
Al-Shatibi, Al-muwāfaqāt, vol. 3, 181.
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Almighty protects the interests of religion through the revelation of signs
and scriptures, and protects life through providing sustenance from the
sky. As such, signs are to religion what sustenance is for life: signs enliven
religion while sustenance enlivens life. Endowing mankind with both is a
perfect blessing.”22
Commenting on the Qur’anic verse above, Al-Qurtubi says, “The
signs revealed by God indicating His oneness and power are combined
with His provision of sustenance because signs are essential for the continuity of religion and sustenance is essential for the continuity of life.”23
It has been established within religious culture, Islamic, and others,
that all sciences revolve around preserving religion and life, keeping in
mind that a substantial portion of religion is devoted to preserving life.
It is narrated that Harun Al-Rashid, the Abbasid caliph, had employed
a skillful Christian physician. In a conversation with ‘Ali bin Al-Husayn,
the physician said, “Your Book (i.e. Qur’an) lacks any information about
medicine despite the two main branches of knowledge being knowledge
of religion and knowledge of the human body.” ‘Ali, in turn, replied, “God
summed up the entire field of medicine with half a verse in our Book.”
The physician asked him what this verse was, and he answered, “God
Almighty says, ‘…and eat and drink, but be not excessive…’ [Qur’an
7:31].” The Christian then said, “There is also no reference to the field of
medicine in any of your Prophet’s narrations.” Once again, ‘Ali replied,
“The Messenger of God, may the peace and blessings of God be upon
him, summarized the field of medicine using a few words.” The physician
asked what they were, and ‘Ali answered, “The stomach is the abode of
diseases, diet is at the forefront of all cures, and each body must be treated
in the way to which it has been accustomed.” At this, the Christian said,
“Your Book and your Prophet have left nothing in the field of medicine
for Galen.”24
22
Al-Fakhr Al-Razi (2000). Mafātīh al-ghayb, 1st edn. Beirut: Dar Al-Kutub Al-‘Ilmiyah,
vol. 27, 38.
23
Al-Qurtubi (2003). Tafsīr Al-Qurtubī, ed. Hisham Samir Al-Bukhari. Riyadh: Dar ‘Alam
Al-Kutub, vol. 15, 299.
24
Al-Qurtubi. Tafsīr Al-Qurtubī, vol. 7, 192.
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Ethics in Medicine 223
One of the rules underpinning Islamic jurisprudence and the objectives
of Sharia outlines that “general interests have precedence over private
interests.” In the application of this rule, we find a close connection
between observing the objectives of medicine and observing the objectives
of Sharia, as well as between preserving life and preserving religion.
In adherence to this rule, jurists have declared that it is an obligation to
prevent the impudent jurist and the ignorant physician from practicing
their professions because the former corrupts religion and the latter
destroys lives. A saying that emerged from this concept states that,
“Religion is corrupted by uneducated jurists, just as bodies are harmed by
uneducated physicians.”
In my opinion, a physician who lacks good morals, regardless of his
medical knowledge, is no less dangerous to people than an ignorant physician. Whereas an ignorant physician must be prevented from practice, a
corrupt physician, on the other hand, must be severely punished.
In order to further explore the objectives of Sharia associated with
ethics, particularly those that are connected to and impact the field of
medicine, the following sections will discuss two main principles in
Islamic ethics:
• God-consciousness;
• Mercy.
As these two principles are discussed, the impact of the different
moral behaviors emerging from each principle, on human conduct in general and medical practice in particular, will be explicitly elaborated on.
2.1.1. God-Consciousness is the Source of Ethics
The practice of God-consciousness in Sharia entails a moral, spiritual, and
psychological state of self-accountability. It requires that an individual be
fully aware and considerate of the consequences of his actions whether in
regards to himself, God, or any of God’s creations.
A person who maintains a state of God-consciousness is one who is
appreciative of God’s blessings and thus is pious towards Him. He reveres
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God and is apprehensive of His vigilance and thus fears disobeying Him.
He is fearful of God’s anger and is wary of His punishment. He is also
cognizant of immoral behavior and its negative impact on himself and
others and therefore refrains from committing any sinful actions.
Hence, God-consciousness is a source of self-discipline and selfimprovement. As ‘Umar bin Abdul-Aziz explains, “A God-conscious
person is restrained; he does not behave as he wishes”,25 meaning that a
person willingly chooses to restrain himself with God-consciousness.
Talq bin Habib, may God have mercy upon him, further elaborates saying, “God-consciousness (taqwá) is obeying God, under the guidance of
God, with the hope of gaining God’s mercy. God-consciousness is also
abstaining from sin, under the guidance of God, out of fear of God’s
punishment.”26
God-consciousness induces one to be vigilant and cautious regarding
all his actions and behaviors. A man once asked Abu Hurayrah, may God
be pleased with him, to explain the meaning of God-consciousness. Abu
Hurayrah asked the man, “Have you ever walked along a thorny path?”
The man replied in the affirmative. Abu Hurayrah then asked, “How did
you walk along it?” The man replied, “Whenever I came across any
thorns, I avoided them, bypassed them, or turned away from them.” Abu
Hurayrah, in turn, asserted, “That is God-consciousness (taqwá).”27
(a) God-Consciousness in the Qur’an and Prophetic Tradition
The religious texts that address the principle of God-consciousness are
abundant and diverse, particularly in the Qur’an. These texts all reinforce
the centrality and pivotal role of God-consciousness in Islam and Sharia
as outlined earlier in this chapter. Further, God-consciousness is also
found to be central across the messages of all God’s prophets and messengers. In the Qur’an, God the Almighty says, “So have God-consciousness
25
Narrated by Al-Bayhaqi in Shu‘ab al-īmān, vol. 5, 63, no. 5788 and Al-zuhd al-kabīr,
357, No. 925, 929. It was also narrated by Al-Baghawi in Sharh al-sunnah, vol. 14, 341.
26
Narrated by Ibn Al-Mubarak in Al-zuhd wal-raqā’iq, no. 1343; by Ibn Abi Shaybah in
Al-Musannaf, vol. 15, 599, No. 30993 and vol. 19, 357, No. 36308; by Abu Nu‘aym in
Al-hilyah, vol. 3, 64; and by Al-Bayhaqi in Al-zuhd al-kabīr, 367, No. 963.
27
Narrated by Al-Bayhaqi in Al-zuhd al-kabīr, 367.
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Ethics in Medicine 225
(taqwá) towards God and obey me” (Qur’an 26:108).28 This order was
admonished by several Messengers29 emphasizing that God-consciousness
is a common purpose and a consistent tenet across all divine religions.
In an extensive hadith, Abu Dharr, may God be pleased with him, was
reported to have said, “I said, ‘O Messenger of God, advise me.’ He said,
‘I advise you to have taqwá towards God, because doing so is the core
issue.’”30 In other words, God-consciousness is the source of all good and
a source of protection from all evil.
(b) The Impact and Effectiveness of God-Consciousness
As described earlier, God-consciousness is an ongoing, internal process of
self-accountability that takes place in both public and private settings.
Often, a person may be able to escape monitoring, pressure, and reproach
by those around him or avoid accountability, especially if he possesses
power due to a position of authority or some rank due to his knowledge
and status. However, in the event of God-consciousness, for one who
observes this principle, it is a constant presence that monitors and guides
his actions day and night, across all locations and settings.
Given the comprehensive, positive impact of observing Godconsciousness, there is no doubt that those who are most in need of maintaining this principle are those individuals who are entrusted with the
souls, bodies, and dignity of others. The beneficial impact of a physician
observing God-consciousness and sincerity in his practice, on the protection of souls and bodies, alleviation of suffering, and conservation of
money and effort, is no less effective than the beneficial impact of a physician’s extensive knowledge and expertise. This is because a Godconscious physician monitors himself and holds himself accountable
ensuring his integrity whether internally or externally. Hence, the integrity
of a God-conscious physician does not arise from nor is contingent upon
a medical oath, just as the integrity of a God-conscious ruler does not
28
Translator’s note: Muhsin Khan translation has been modified to better reflect the
context of the text.
29
See Qur’an 3:50; 26:108, 110, 126, 131, 144, 150, 163, 179; and 43:63.
30
Narrated by Ibn Hibban, Kitāb al-birr wal-ihsān, vol. 2, 78; Abu Nu‘aym, in Al-hilyah,
vol. 1, 168.
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emerge from a constitutional oath. Rather, those individuals who lack the
internal virtue of God-consciousness and self-accountability will fail any
oath, be it Greek or Islamic.
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2.1.2. Mercy and Compassion in Medicine and Sharia
Mercy, as an ethical principle, is a cornerstone of both Sharia and medicine. Some scholars encapsulate the objectives and obligations of Sharia
with two concise statements: “glorifying the Creator and being merciful
towards creation.”
In summary, the term “mercy” encompasses gentleness, compassion,
kindness, forgiveness, sympathy, affection, and all associated actions,
including preventing harm, promoting benefit, providing advice, alleviating pain, or offering assistance. It also represents countering acts of cruelty, severity, vulgarity, and harm.
(a) Mercy in the Qur’an and Prophetic Tradition
The prevalence of the term “mercy” and its derivatives in the Qur’an
and Prophetic Tradition, covering various aspects of life, can be enumerated in the hundreds. This explicitly emphasizes mercy as a major
principle in religion and a general objective of Sharia. Below are some
examples of verses and narrations from the Qur’an and Prophetic
Tradition respectively:
(i) In the Qur’an
(1) The divine books are sources of mercy:
• “O mankind, there has come to you instruction from your Lord and
healing for what is in the breasts and guidance and mercy for the
believers. Say, ‘In the bounty of God and in His mercy — in that
let them rejoice; it is better than what they accumulate’” (Qur’an
10:57–58).
• “Say, ‘I only follow what is revealed to me from my Lord. This
[Qur’an] is enlightenment from your Lord and guidance and
mercy for a people who believe.’ So when the Qur’an is recited,
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•
•
•
•
then listen to it and pay attention that you may receive mercy”
(Qur’an 7:203–204).
“And We had certainly brought them a Book which We detailed by
knowledge — as guidance and mercy to a people who believe”
(Qur’an 7:52).
“So there has [now] come to you a clear evidence from your Lord
and a guidance and mercy” (Qur’an 6:157).
“Then We gave Moses the Scripture, making complete [Our favor]
upon the one who did good and as a detailed explanation of all
things and as guidance and mercy that perhaps in [the matter of] the
meeting with their Lord they would believe” (Qur’an 6:154).
“So is one who [stands] upon a clear evidence from his Lord [like
the aforementioned]? And a witness from Him follows it, and
before it was the Scripture of Moses to lead and as mercy” (Qur’an
11:17).
(2) Familial and marriage relationships should be characterized with
mercy, affection, and peace:
• “And of His signs is that He created for you from yourselves mates
that you may find tranquility in them; and He placed between you
affection and mercy. Indeed in that are signs for a people who give
thought” (Qur’an 30:21).
• “And [mention] Job, when he called to his Lord, ‘Indeed, adversity
has touched me, and you are the Most Merciful of the merciful.’ So
We responded to him and removed what afflicted him of adversity.
And We gave him [back] his family and the like thereof with them as
mercy from Us and a reminder for the worshippers [of God]” (Qur’an
21:83–84).
• “And We granted him his family and a like [number] with them as
mercy from Us and a reminder for those of understanding” (Qur’an
38:43).
Mercy is integral within all of God’s ordinances, and His obligations
serve as a pathway to mercy: “The believing men and believing women
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are allies of one another. They enjoin what is right and forbid what is
wrong and establish prayer and give zakāh and obey God and His
Messenger. Those — God will have mercy upon them. Indeed, God is
Exalted in Might and Wise” (Qur’an 9:71).
(ii) In the Prophetic Tradition
(1) It was narrated on the authority of Abdullah bin Amr, may God be
pleased with them, that the Messenger of God (PBUH) said, “The
Compassionate One has mercy on those who are merciful. If you
show mercy to those who are on the earth, He Who is in the heaven
will show mercy to you.”31
(2) It was narrated on the authority of Jarir bin ‘Abdullah that the
Messenger of God (PBUH) said, “God will not be merciful to those
who are not merciful to mankind.”32
(3) Imam Al-Bukhari allocated several chapters in his Sahīh for topics of
mercy, including chapter 27 in the “Book of Manners” named, “chapter of showing mercy to people and animals.” One of the hadiths
included in this chapter was narrated on the authority of Abu Hurayrah
that the Messenger of God (PBUH) said, “A man felt very thirsty
while he was on the way, there he came across a well. He went down
the well, quenched his thirst and came out. Meanwhile he saw a dog
panting and licking mud because of excessive thirst. He said to himself, ‘This dog is suffering from thirst as I did.’ So, he went down the
well again and filled his shoe with water and watered it. God thanked
him for that deed and forgave him.” The people said, “O God’s
Apostle! Is there a reward for us in serving the animals?” He replied,
“Yes, there is a reward for serving any animate (living being).”33
31
Narrated by Ahmad in Al-musnad, no. 6494 on the authority of ‘Abdullah bin ‘Amr; Abu
Dawud in Al-adab, no. 4941; and Al-Tirmidhi, Al-birr wal-silah, no. 1925 and he said:
“This is a fair authentic hadith.” Translator’s note: translation of Professor. Ahmad Hasan
(Abu Dawud, book 41, No. 4923).
32
Narrated by Al-Bukhari, Al-adab, no. 6013 and Muslim, Al-fadā’il, no. 2319. Translator’s
note: translation of Muhsin Khan (USC web, Bukhari, vol. 9, book 93, No. 473).
33
Narrated by Al-Bukhari, vol. 3, 132–133, No. 2466 and vol. 8, 9–10, No. 6009 and by
Muslim, vol. 4, 1761, No. 2244. Translator’s note: translation of Muhsin Khan (USC web,
Bukhari, vol. 3, book 43, No. 646).
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Ethics in Medicine 229
It was narrated on the authority of Abu Hurayrah that the Prophet
(PBUH) said, “A prostitute saw a dog moving around a well on a hot day
and hanging out its tongue because of thirst. She drew water for it in her
shoe and she was pardoned (for this act of hers).”34
Al-Hasan bin Battal, generally commenting on hadiths included in
this chapter of Sahīh Al-Bukhārī, says,
These hadiths urge showing mercy toward all people, including believers and disbelievers, and toward animals. Doing so is a way to expiate
one’s sins. Therefore, sagacious believers should have mercy upon people and animals, which were not created for no purpose. Everyone is
responsible in front of God for everyone he is entrusted with, be it a
person or an animal that cannot speak of the pain they suffer from.
Mercy needs also be shown toward animals that one does not own.
There was a man who watered a dog in the desert, although the dog was
not his own, and God forgave him as he descended a well and brought
water in his shoe to the dog. This also applies to feeding animals, as the
Prophet, may peace and blessings of God be upon him, said, “If any
Muslim plants any plant and a human being or an animal eats of it, he
will be rewarded as if he had given that much in charity.”35 In addition
to watering and feeding animals, it is also recommended not to burden
them beyond their capacity out of showing mercy toward them. Animals
should not be beaten up, harmed, or used at night or out of work time.
We have been forbidden to put servants to work at night because night
is their time of rest, as they work during the day to their masters. The
same applies to using animals.36
Al-‘Izz bin ‘Abd Al-Salam indicated how the two attributes of
mercy and compassion of God should be applied by people: “Mercy
34
Narrated by Muslim, No. 2245 and by Ahmad in Al-musnad, No. 10583. Translator’s
note: translation of Abdul Hamid Siddiqui (USC web, Muslim, book 6, No. 5578).
35
Narrated by Al-Bukhari, Al-muzāra‘ah, no. 2152 and Muslim, Al-musāqāh, No. 2904 on
the authority of Anas bin Malik. Translator’s note: translation of Muhsin Khan (USC web,
Bukhari, vol. 8, book 73, No. 41).
36
Ibn Battal, Sharh Sahīh Al-Bukhārī, Riyadh: Maktabat Al-Rushd, vol. 9, 219–220.
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should be observed as much as possible toward everything including
even flies and ants.”37
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(b) Mercy and Euthanasia
One of the contentious medical debates associated with the ethic of
mercy is that of mercy killing (euthanasia). Euthanasia involves the physician ending the life of a chronically-ill patient based on the patient’s
request or with permission from the patient’s family in cases where the
patient is in a chronic coma. The justifications often presented for this
action involve arguments of mercy and compassion towards ending the
patient’s suffering.
This issue has been extensively explored within Islamic law. Muslim
scholars unanimously agree on the prohibition of euthanasia, and it is
considered to be a proscribed killing of a human being. However, it is
neither the purpose nor focus of this chapter to present an in-depth discussion of this issue. The aim here is merely to focus on the ethical aspects
of the debate so as to explore whether euthanasia is indeed a merciful
solution to ending a patient’s suffering.
Euthanasia, as a solution, is both superficial and shortsighted in its
approach. Firstly, it increases the potential of taking risks with human life
and undermining its sanctity. This is especially true when a probability of
cure exists, however small it may be.
In addition, any level of pain could not be weighed against the cost
of ending a human life. If we were to prioritize preventing pain over
protecting life, then the act of suicide would be permissible in cases
where individuals suffer from chronic pain and have no hope of recovery.
Further, allowing euthanasia as an option may result in the hindrance of
medical advancement that should not simply surrender to despair but
rather endeavor to seek the cure.
Moreover, the concept of mercy in Islamic ideology encompasses
mercy in the afterlife, which entails repentance, patience, forgiveness,
and reward. There are several authentic Prophetic traditions reinforcing
the concept that pain serves to erase sins and elevate one’s status as a
37
‘Izz bin ‘Abd Al-Salam, Shajarat al-ma‘ārif wal-ahwāl wa sālih al-aqwāl wal-a‘māl.
Bayt Al-Afkar Al-Duwaliyah: 40.
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Ethics in Medicine 231
means of mercy and alleviation in the afterlife. This was expressed by
the Prophet (PBUH) in his saying, “No fatigue, nor disease, nor sorrow,
nor sadness, nor hurt, nor distress befalls a Muslim, even if it were the
prick he receives from a thorn, but that God expiates some of his sins
for that.”38
The Prophet (PBUH) also said, “Calamities will continue to befall
believing men and women in themselves, their children and their wealth,
until they meet God with no burden of sin.”39 This is a great form of
divine mercy. The purpose of all this being to encourage the patient to
endure the pain of his illness, remain hopeful, and safeguard his life.
3. Conclusion
The following ethical principles serve as a summative outline of the concepts addressed in this chapter:
(i) The purpose and mission of medicine should be promotion of the
physical, mental, and psychological health of all persons.
(ii) The main, essential objectives of medicine intersect with three of the
objectives of Sharia; namely, preserving life, preserving offspring,
and preserving intellect.
(iii) The two ethics, God-consciousness and mercy, are essential ethical
principles for those professionals entrusted with the protection of
people’s lives and with maintaining public and private health for
society and individuals.
38
Narrated by Al-Bukhari, Al-marḍá, no. 5641 and Muslim, Al-birr wal-silah, No. 2573
on the authority of Abu Hurayrah. Translator’s note: Translation of Muhsin Khan (USC
web, vol. 7, book 70, No. 545).
39
Narrated by Ahmad in Al-musnad, No. 7859. It was also narrated by Al-Tirmidhi,
Al-zuhd, No. 2399, and he said it is a fair authentic hadith, on the authority of Abu
Hurayrah.
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May 2, 2013
14:6
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PST˙ws
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Response by Hassan Chamsi-Pasha
to Raissouni’s Paper
Hassan Chamsi-Pasha
I read with great interest the paper of Sheikh Ahmed Raissouni who laid
down an approach to medical ethics based on the higher objectives of
Sharia. Sheikh Raissouni is an authority in the field of the fundamentals
of Islamic jurisprudence (usūl al-fiqh) and the higher objectives of Sharia;
hence his paper reflects his deep knowledge and understanding of this
subject. I would like to emphasize a few points in relation to the issues
discussed in his paper.
1. Islam and Medicine
The relation between Islam and medicine is without doubt a close one, as
stated by Sheikh Raissouni.1 Islam supports the use of science, medicine,
and biotechnology as ways to arrive at appropriate solutions that alleviate
human suffering.2 Thus, we find Muslims throughout the world are eager
1
Hormoz Ebrahimnejad (2011). What is ‘Islamic’ in Islamic medicine? An overview, in
Feza Günergun and Dhruv Raina (ed.). Science between Europe and Asia. Boston, MA:
Springer: 259–270.
2
Marcia C. Inhorn (2003). Local Babies, Global Science: Gender, Religion and In Vitro
Fertilization in Egypt. New York, NY: Routledge.
233
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to benefit from the latest medical advancements and in many cases prefer
Western biomedicine to its alternatives.3,4 Furthermore, Islamic religious
authorities play an important role in encouraging techno-scientific developments through their fatwas, which permit some medical advances while
they place limitations on other practices of medicine.
2. Roots of Medical Ethics in the Qur’an
As Western ethics has developed into a philosophical science, it has
moved away from a Christian conception of good and evil to draw more
upon human reason and experience as the arbiter between right and
wrong action. This shifting of ethics to a more philosophical formulation does not have an equivalent in the Islamic intellectual discourse.
While Islamic ethics does incorporate various philosophical traditions,
it still mainly draws its sources from religious texts and holds a religious
worldview.5
The discussion on medical ethics in Islamic law is but a branch of the
high status ethics in general has in Islam as seen in the Qur’an, the
Tradition of the Prophet Muhammad (PBUH), and the understanding of
the Islamic Sharia. Sheikh Raissouni clearly emphasizes that the same
standard of ethical values and principles should guide the physician in
both his private and professional life.
A person who lacks moral values in his private life, no matter how
knowledgeable and skilled he is in medicine, is dangerous and harmful to
people and cannot be trusted in professional activities, even if he has the
highest professional and technical qualifications. It is impossible for a
person to live by two different ethical standards, adopting one set of
ethical principles in his private life and contradictory principles in his
3
Morgan Clarke (2009). Islam and New Kinship: Reproductive Technology and the
Shariah in Lebanon. New York, NY: Berghahn.
4
Marcia C. Inhorn and Gamal I. Serour (2011). Islam, medicine, and Arab-Muslim refugee
health in America after 9/11. Lancet 378 (9794): 935–943.
5
Aasim Padela (2007). Islamic medical ethics: A primer. Bioethics 21(3): 169–178.
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professional life.6 Truthful is God the Almighty when He says: “God has
not made for a man two hearts in his interior…” (Qur’an 33:4).
The following verses from the Qur’an are most suited as a guide for
the personal characteristics of the physician. God says,
And [mention, O Muhammad], when Luqman said to his son while he
was instructing him, “O my son, do not associate [anything] with God.
Indeed, association [with him] is great injustice.” And We have enjoined
upon man [care] for his parents. His mother carried him, [increasing her]
in weakness upon weakness, and his weaning is in two years. Be grateful
to Me and to your parents; to Me is the [final] destination. But if they
endeavor to make you associate with Me that of which you have no
knowledge, do not obey them but accompany them in [this] world with
appropriate kindness and follow the way of those who turn back to Me
[in repentance]. Then to Me will be your return, and I will inform you
about what you used to do. [And Luqman said], “O my son, indeed if
wrong should be the weight of a mustard seed and should be within a
rock or [anywhere] in the heavens or in the earth, God will bring it forth.
Indeed, God is Subtle and Acquainted. O my son, establish prayer, enjoin
what is right, forbid what is wrong, and be patient over what befalls you.
Indeed, [all] that is of the matters [requiring] determination. And do not
turn your cheek [in contempt] toward people and do not walk through the
earth exultantly. Indeed, God does not like everyone self-deluded and
boastful. And be moderate in your pace and lower your voice; indeed,
the most disagreeable of sounds is the voice of donkeys.” (Qur’an
31:13–19).
Sheikh Raissouni elaborated on the issue of mercy and stressed its
importance in the field of medicine. God says, addressing His Prophet
Muhammad (PBUH), “So by mercy from God, [O Muhammad], you were
lenient with them. And if you had been rude [in speech] and harsh in heart,
they would have disbanded from about you. So pardon them and ask forgiveness for them and consult them in the matter. And when you have
6
Abdul Rahman Amine and Ahmed Elkadi (1981). Islamic code of medical professional
ethics. Journal of the Islamic Medical Association of North America 13: 108–210.
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decided, then rely upon God. Indeed, God loves those who rely [upon
Him]” (Qur’an 3:159).
Based on the above, the Muslim physician must believe in God and
in what Islamic teachings call for, regarding both his private and public
life. He must be grateful to his teachers and respectful towards his
elders. He must also be humble, merciful, patient, and forgiving. He
should follow the path of the believers and always seek God’s support
and assistance.7
No doubt a physician with the above-mentioned virtues is capable
of fulfilling the professional requirements of this noble occupation. The
first professional requirement is having the appropriate knowledge. God
says in the Qur’an, “…Say, ‘Are those who know equal to those who do
not know?’…” (Qur’an 39:9). God also says, “…Only those fear God,
from among His servants, who have knowledge…” (Qur’an 35:28).
Therefore the believer is expected to always seek knowledge and
understanding. God says, “…and say, ‘My Lord, increase me in knowledge’” (Qur’an 20:114). The physician must also abide by the legal rules
regulating his profession provided they do not violate Islamic principles. The need to respect law and order is reflected in the following
Qur’anic verse, in which God says, “O you who have believed, obey
God and obey the Messenger and those in authority among you…”
(Qur’an 4:59).
When entrusted with the life and care of a patient, the physician must
offer the needed advice with consideration for both the patient’s body and
mind, always remembering his basic obligation to enjoin what is right and
forbid what is wrong. The physician must respect the patient’s confidentiality, reflecting God’s description of the believers, “And they who are to
their trusts and their promises attentive” (Qur’an 23:8).
3. Islam and Secularization
Sheikh Raissouni pointed out the fact that Islam rejects secularization;
secularization here meaning humans ruling their lives with no regard or
consideration to a religion or a higher spiritual authority. Some secular
7
Ibid.
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237
proponents believe following the divine law would lead to hardship.8 This
may be the basis as to why some societies have separated the church from
everyday life and replaced God’s rules with man-made laws and guidelines. This secular reasoning evolved when societies were faced with
ethical and practical dilemmas. No doubt this reasoning can be contradictory as it lacks logical coherence when it is not based on an underlying
coherent system of ethical values.9
Islam is not only a religion with rituals; it is a way of life. Once an
individual accepts Islam, he is to live by its rulings in all of his affairs, in
accordance with God’s statement, “But no, by your Lord, they will not
[truly] believe until they make you, [O Muhammad], judge concerning
that over which they dispute among themselves and then find within
themselves no discomfort from what you have judged and submit in [full,
willing] submission” (Qur’an 4:65) and,
And We have revealed to you, [O Muhammad], the Book in truth,
confirming that which preceded it of the Scripture and as a criterion
over it. So judge between them by what God has revealed and do not
follow their inclinations away from what has come to you of the truth.
To each of you We prescribed a law and a method. Had God willed, He
would have made you one nation [united in religion], but [He intended]
to test you in what He has given you; so race to [all that is] good. To
God is your return all together, and He will [then] inform you concerning that over which you used to differ. And judge, [O Muhammad],
between them by what God has revealed and do not follow their inclinations and beware of them, lest they tempt you away from some of
what God has revealed to you. And if they turn away — then know that
God only intends to afflict them with some of their [own] sins. And
indeed, many among the people are defiantly disobedient (Qur’an
5:48–49).
8
Shlomi Tal (2001). Necessity and Primacy of Secularism. Institute of Secularization of
Islamic Society. Available online via http://www.secularislam.org/separation/tal.htm
(retrieved 13 November 2013).
9
Omar Hasan Kasule (2004). Ethics and Etiquette of Human Research. Paper presented
at the International Scientific Convention jointly organized by the Jordan Society for
Islamic Medical Studies, the Jordan Medical Association, and the Federation of Islamic
Medical Association in Amman, Jordan 15–17 July 2004.
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One might ask what is the relationship of such rejection of secularization in Muslim communities and biomedical research ethics for example? The simple answer is that certain research projects are considered
unlawful under Sharia. The best example here is the use of surrogacy for
the treatment of infertility and the use of tissue cloning and gene therapy
with the aim of controlling the genetic characteristics of an embryo,
which is tantamount to interfering with God’s will.10
4. The Four Principles
Although Sheikh Raissouni did not discuss the principlist approach to
medical ethics as it is out of the scope of his paper, I will discuss it very
briefly. The principlist approach to biomedical ethics proposed by two
American bioethicists, Tom Beauchamp and James Childress, has received
some attention from Muslim scholars.11 According to this approach, there
are four general principles of biomedical ethics: (i) respect for autonomy,
(ii) beneficence, (iii) nonmaleficence, and (iv) justice.
Several authors claim that the roots of the four principles presented by
Beauchamp and Childress are clearly identifiable in Islamic tradition as
well.12,13 Beneficence is strongly connected to the principle of nonmaleficence, but it is so connected to other principles as well that we can say
the principle of beneficence is the starting point of all kinds of human
relations. PBUH said, “The best of you is the one who is most beneficial
to others.”14 Similarly, Islam forbids all kinds of actions that may harm a
person’s health and life. In the Islamic tradition, many statements stress
the avoidance of harm to others. The PBUH commanded that, “There
should be neither harming nor reciprocating harm.”15
10
Raafat Y. Afifi (2007). Biomedical research ethics: An Islamic view: Part I. International
Journal of Surgery 5(5): 292–296.
11
Bagher Larijani and Farzaneh Zahedi (2008). Contemporary medical ethics: An overview
from Iran. Developing World Bioethics 8(3): 192–196.
12
Sahin Aksoy and Abdurrahman Elmai (2002). The core concepts of the ‘Four principles’
of bioethics as found in Islamic tradition. Medical Law Review 21: 211–224.
13
Gamal I. Serour (1994). Islam and the four principles, in Raanan Gillon (ed.). Principles
of Healthcare Ethics. New York: Chichester Wiley: 75–91.
14
Muhammad Nasir Al-Din Al-Albani, comp., Sahīh al-jāmi‘ no. 3289.
15
Sahīh al-jāmi‘, no. 7517.
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Islam does not permit man to act as he wishes without limits but
instead outlines for him certain rules to abide by. These rules are derived
from the Qur’an and the life of the PBUH. It is reported in various verses
of the Qur’an that God revealed the Qur’an as a clarification for people
and a guide for them so that they may lead the best life and that the PBUH
is the best example and role model.16
Aksoy and Elmai cite many instances within Islamic texts that urge
respect for a patient’s autonomy.17 Van Bommel says, “For a Muslim
patient absolute autonomy is very rare, there will be a feeling of responsibility towards God, and he or she lives in a social coherence, in which
influences of the imam and relatives play their roles.”18 Consequently,
personal choices are recognized only if they prove to be the “right” ones.
The Noble Qur’an gives great importance to the principle of justice; about
16 of its verses talk about this principle.19
According to these verses, the main purpose behind sending the
prophets was to establish justice in the world. God says, “We have already
sent Our messengers with clear evidences and sent down with them the
Scripture and the balance that the people may maintain [their affairs] in
justice…” (Qur’an 57:25).
5. Euthanasia
Finally, Sheikh Raissouni touched briefly on the subject of euthanasia. He
stated that life is given by God and cannot be taken away except by Him
or with His permission and that preservation of life is one of the five
foundational objectives of Islamic Sharia.20
Human beings are considered to be responsible stewards of their bodies, which are viewed as gifts from God. The sanctity of human life is
16
Sahin Aksoy and Ali Tenik (2002). The ‘four principles of bioethics’ as found in 13th
century Muslim scholar Mawlana’s teachings. BMC Medical Ethics 3: 4.
17
Sahin Aksoy and Abdurrahman Elmai (2002). The core concepts of the ‘four principles’
of bioethics as found in Islamic tradition, Medical Law Review 21: 211–224.
18
Abdulwahid van Bommel (1999). Medical ethics from the Muslim perspective. Acta
Neurochirurgica Supplement 74: 17–27.
19
Kiarash Aramesh (2008). Justice as a principle of Islamic bioethics. The American
Journal of Bioethics 8(10): 26–27.
20
Al-Shatibi (1997). Al-Muwāfaqāt, 2. Khobar: Dar Ibn Affan: 20.
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affirmed in the Qur’an. No one can deprive another of his life: “…And
do not kill the soul which God has forbidden [to be killed] except by
[legal] right…” (Qur’an 6:151) and, “Because of that, We decreed upon
the Children of Israel that whoever kills a soul unless for a soul or for
corruption [done] in the land — it is as if he had slain mankind entirely.
And whoever saves one — it is as if he had saved mankind entirely…”
(Qur’an 5:32).
The physician therefore has no right to terminate any human life
under his care. Taking away life is only the domain of the One who gives
life, and He is God. True, there is pain and suffering [at the end of a terminal illness], but Muslims believe there is immeasurable reward from
God for those who patiently persevere in suffering. “…Indeed, the patient
will be given their reward without account” (Qur’an 39:10).
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Script of Oral Discussions
(Day 1, Session 2)
After Abdul Sattar Abu Ghuddah presented his paper, the following
discussion took place.
Hassan Chamsi-Pasha
A number of papers have been published demonstrating that the four principles of biomedical ethics exist in Islam. Sheikh Abu Ghuddah mentioned a book earlier entitled Ethics of the Physician (Akhlāq al-ṭabīb) of
Abu Bakr Al-Razi (known also as Rhazes). It mentions ethical issues,
such as respecting the confidentiality of the patient, refraining from arrogance, treating the poor, and putting one’s trust in God. All these principles were written about more than a 1,000 years ago, in the 9th century.
Another important book in this matter is called Practical Ethics of the
Physician (Adab al-ṭabīb) by Al-Ruhawi. It is believed to be the first
known book about the practical ethics of the physician and one of the
foundational books on the subject. Martin Levey translated it into English
in 1967. Sahin Eksoy considers it the first book on ethics in Islamic
medicine. Dr. Padela described it as an attestation to the ability of Islamic
thinkers to integrate philosophical principles into Islamic methodology.
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Al-Ruhawi’s Practical Ethics of the Physician consists of 20 chapters
addressing all sorts of medical ethics. Although we do not have the time
to discuss them all, I would like to concentrate on the three tenets that
Al-Ruhawi highlighted in his introduction.
The first tenet a doctor should hold true is that behind every created
being exists the One Creator who is Most Wise and Able to do all things.
The second tenet entails a doctor’s believing in firm affection towards
God and devoting himself fully to Him in mind and soul, by choice. Third,
a doctor should believe that God sent messengers to mankind in order to
guide them towards good.
It is for this reason that a doctor must believe the human mind alone
is not sufficient, and so, before they begin examining a patient, Muslim
doctors should say, “In the name of God, The Most Gracious, The Most
Merciful.” For the 30-some years I have practiced medicine, by the Grace
of God, I cannot remember a single case of examining a patient — whether
in Syria, England, or Saudi Arabia — except that I began by saying “In the
name of God, the Most Gracious, the Most Merciful.” I say it out loud,
even in England, in English. Saying this phrase provides me with reassurance and helps me remain hopeful for success in my work. It reminds the
doctor that he is not the healer but rather God Almighty is. When the doctor says, “In the name of God,” it gives the patient spiritual energy and
makes him feel a connection to God.
As Sheikh Raissouni and Sheikh Abu Ghuddah mentioned, God likes
for a person, if he does work, that he does it with meticulousness and
precision (itqān). When somebody suffers from a heart problem, within
hours the entire area dies. So here is an instance where seeking excellence
is incredibly important. The doctor must take into account that time is a
key factor and so should carry out the diagnosis and start treatment within
minutes if possible.
There is no medical intervention that does not carry a risk for medical
complications. We must clarify any possible complications to the patient
before starting any medical or surgical intervention. Indeed, anything
could happen during a surgical intervention that the patient would not be
able to foresee. Of course, ultimately it is only God who knows what will
happen.
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Script of Oral Discussions (Day 1, Session 2) 243
We must also be truthful when we speak with the patient about
undergoing any procedure such as gastric banding. Often the patient is
made to believe that it is going to be a very easy procedure and that it will
not have any subsequent complications. This is of course not the case, and
this should be communicated to patients honestly. We distribute to patients
before they undergo a medical procedure books that provide them with
guidelines about the process and clarify the probabilities of various side
effects and complications. As Sheikh Abu Ghuddah asserted earlier, the
doctor has a responsibility to be truthful to the patient. He is held accountable not only before courts or medical authorities but also before God.
Another issue is that doctors need to smile more! Some doctors snarl
in front of their patients. Many patients say that half of their cure involves
their doctor smiling to them. Prophet Muhammad (PBUH) said it is a
form of charity when you smile at another person. Also among the sayings
of the PBUH are those that emphasize how people treat one another in
general. Nowadays, the relationship between physicians and their colleagues is sometimes disappointing. A physician may negatively criticize
a colleague due to jealousy, enmity, or another trait that contradicts with
Islamic Sharia. Arrogance is also an unfortunate trait that many doctors
are prone to exhibiting. Some doctors think they are so important that they
will not talk to you unless you present them with your ID card! PBUH
said that whoever has even the smallest trace of pride or arrogance cannot
enter Paradise or would not be admitted to Paradise. These are the ethical
concepts and ideals by which we should abide.
We should also strive to be true role models in all our actions. In
England, we had a consultant respiratory physician who was a heavy
smoker. His ashtray would fill up with more than 30 or 40 cigarettes by
the end of each day, and yet he advised patients to quit smoking. In what
way is this doctor being a good role model? It is likewise important for a
physician to care about his appearance and not to visit a patient while he
looks untidy. PBUH said that God is beautiful and loves beauty. This is a
Prophetic principle that we should abide by in general and in particular
with our patients.
Breaching patient confidentiality is prohibited as Sheikh Abu Ghuddah
already mentioned. A doctor has access to many personal details about his
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or her patients. In addition, medical files are no longer only paper files;
they are recorded on computers and databases. We once had a nurse who
entered the system and saw all of her colleagues’ medical records and lab
results. As soon as this was found out, she was expelled from work immediately because this was an infringement of others’ right to confidentiality.
The point is that a patient’s file of information comes from different parts
of the hospital — it is not just between him and his doctor — and could
be available to anyone who has access to this file. As a result, respecting
confidentiality becomes even more significant. Certain doctors reveal
confidential information simply to show off their knowledge about what
happens in certain cases. These are all things that Islam prohibits. The
PBUH said that for he who conceals (the faults of) a Muslim, God would
conceal his faults in this world and in the Hereafter.
Mohammed Ghaly
In order to create a path for our discussion, I will attempt to draw a link
between the paper presented by Sheikh Abu Ghuddah just now and the
paper presented by Sheikh Raissouni that was discussed in an earlier session. Sheikh Raissouni addressed the question of principles and the search
for them. He spoke to us about the attempts of Islamic scholars to find the
core values (ummahāt al-faḍā’il). He then detailed to us what he had personally arrived at, which are the two principles of God-consciousness
(taqwá) and mercy (raḥmah). Sheikh Abu Ghuddah took us in a different
direction, one that involved the etiquettes of the physician. He mentioned
that among Islamic scholars’ search for the etiquettes of the physician was
Abu Bakr Al-Razi and Dr. Chamsi-Pasha mentioned Al-Ruhawi. So it is
apparent that a search has been taking place for centuries, whether it was
for general ethics like in the case of Ibn Miskawayh and Al-Ghazali or for
more specific ethics concerning the medical field. So this subject is not
new to Islam and has been a topic of research for a long time.
Second, in their search for these ethical issues, Islamic scholars were
not closed-minded. They did not limit themselves to looking only at Islamic
texts; they also integrated related works from the traditions of other peoples. Ibn Miskawayh, for example, and others looked into the works of
Greek philosophers. The books of Al-Ruhawi and Al-Razi are replete with
quotes from Galen, Hippocrates, and others. However, they tried to frame
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Script of Oral Discussions (Day 1, Session 2) 245
these principles within the context of Islam and its principles. So in our
present efforts to discuss a universal perspective on biomedical ethics and
to answer the question of how to interpret them from an Islamic perspective, we are not coming up with something new in principle. Instead, it is
the continuation of the constant communication across cultures that began
long ago.
Sheikh Abu Ghuddah mentioned an important term in the title of his
paper: the “governing principles” (al-mabādi’ al-ḥākimah). It was translated into English as just “principles,” but it is important to include the
adjective, “governing.” Another interesting point about Sheikh Abu
Ghuddah’s paper was that in the body of the paper itself, when he introduced the 12 main items, he called them “Islamic ethics in medicine” and
not “governing principles.” Furthermore, while Sheikh Abu Ghuddah
detailed 12 ethics, Sheikh Raissouni specified only two. The two Sheikh
Raissouni included also show up in Sheikh Abu Ghuddah’s paper, directly
or indirectly. So we have both commonalities and differences between the
two papers that necessitate discussion so as to agree on some conclusions.
Jasser Auda
Among what we concern ourselves with in this center is how Islam can
contribute to the world when it comes to the field of ethics, in order to
serve humanity and civilization in general. There is no doubt that Islam
has a lot to offer when it comes to biomedical ethics specifically. However,
as Dr. Ghaly pointed out, this discipline is built on an inherited tradition
that is not only Islamic but includes other nations and schools of thought,
and Islam contributed or added to it. My question to Sheikh Abu Ghuddah
is: Can Islamic Sharia give or present something to non-Muslims? As we
are speaking about universal biomedical ethics, is it possible to speak of
the universality of Islamic Sharia in this regard?
Abdul Sattar Abu Ghuddah
Islamic Sharia encompasses many areas, including belief or creed, acts of
worship, daily transactions between people, the legal system, rules and
regulations, and consequences for crime. Apart from the creed and acts of
worship that are specific to Muslims, these areas are universal and are
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derived plainly from the principle of justice. They come from the attempt
to preserve the rights of all and avoid that which causes disputes such as
ignorance, betrayal, deception, and taking money fraudulently as is the
case with usury and gambling. These ideals are expected of all of humanity,
Muslims and non-Muslims alike.
It is interesting that we find many occasions in history when nonMuslims resorted to Muslim courts to deal with their cases, especially
when they involved matters of inheritance. This is because many legal
systems outside the Islamic tradition lacked elaborate processes in this
area. For example, in the West, a person could leave his estate or money
to literally anyone, including an animal if he so chose, and deprive from
his money whomever he chose. In Islamic Sharia, however, there are clear
criteria for how inheritance money is to be distributed. It is a structure that
Muslims are proud and grateful to have. We have seen many Christian
families request from a Muslim judge to divide their inheritance amongst
them according to Islamic principles.
In addition, the world’s recent financial crisis revealed how Islamic
banking institutes that maintained Sharia standards did not suffer as much
as non-Islamic banks. This left people considering why the Islamic system
survived with fewer negative impacts, and it put Islamic banking in higher
demand. There was more interest in knowing what exactly the Islamic
principles of financial transactions are and how they work. For example,
Islam prohibits the charging of interest on loans.
This drew attention of all people, not just Muslims. Accordingly and
more generally, if others do seek our contribution or guidance in certain
matters, we try to help. However, needless to say, we do not interfere with
the freedom of other people or nations to choose whichever systems they
desire. We do not impose our methods on them, and we always respect
their freedom of choice regarding their religious beliefs. This is my view
on the universality of the Islamic Sharia, apart from acts of worship and
matters of creed that each person chooses for him or herself.
Ali Al-Qaradaghi
I have some clarifying questions. In his paper, Sheikh Abu Ghuddah mentioned the balance between when a doctor should guard his patients’
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Script of Oral Discussions (Day 1, Session 2) 247
secrets and when he should disclose them in specific cases, according to
the resolution arrived at by the International Islamic Fiqh Academy.
I believe this balance is what we were looking for earlier this morning and
the resolution answers our questions in this regard.
I noticed the words “governing principles” (al-mabādi’ al-ḥākimah)
in the title of Sheikh Abu Ghuddah’s paper and was under the impression
that Sheikh Abu Ghuddah would specify to us what the governing principles actually are. I was also hoping he would clarify the distinction
between governing principles, non-governing principles, and what are not
considered to be principles at all. In fact, the title of his paper, “The
Governing Principles of Islamic Ethics in Medicine,” is comprises two
main points. We need to understand the current usage of the word principles (mabādi’) in its meaning both as “comprehensive principles”
(kullīyāt) and as “fundamentals” (uṣūl), contrary to its usage in previous
generations.
The traditional definition of the term principle (mabda’) in Arabic has
historically been the “beginnings” or “introductions,” according to scholars of the Arabic language. Therefore, the terms “comprehensive principles” and “fundamentals” are in fact not far from the traditional meaning.
I come now to my point. It is imperative that we distinguish principles
from that which are not principles as Dr. Beauchamp did when he distinguished between the criteria (mi‘yārīyah) of ethics on the one hand and
the individual ethics themselves on the other hand. When he defined ethics in four elements, he clarified that he is not talking about the categories
or types of ethics; instead, he is talking about the criteria [or ways of
measuring]. So we are in need of these criteria, and I hope our discussion
will address this point. This is the first remark.
My second point concerns the 12 items that Sheikh Abu Ghuddah
included in his paper. They all are of course based on Sharia, but I did
not find them all to be issues of ethics, strictly speaking. For instance, in
regards to acquiring the appropriate medical knowledge and experience,
that is a practical and legal matter since no physician will be certified
without this knowledge. While it is consistent with ethical considerations, it is not necessarily an ethical issue in and of itself. The same can
be said about four more of the items: a doctor’s conformity with standard
occupational principles, religious (Sharia-based) knowledge of rulings
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professional laws and regulations.
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Mohammed Ghaly
We will gather all questions and comments and allow Sheikh Abu
Ghuddah the chance to respond afterward.
Annelien Bredenoord
What strikes me about what I have heard thus far regarding Islamic
medical ethics is that it is an ethics of the physician. It is much about the
virtues of being a good physician and about the principles guiding the
conduct of a physician. The difference in Western bioethics, and also in
the four principles, is that we are more focused on medical ethics in society and on the patient’s ethics. What I have heard so far about professional
ethics, or the ethics of the doctor, is almost the same as the ethics we teach
our medical doctors, and they are rooted in the principles of beneficence
and nonmaleficence.
However, our other two universal principles, autonomy and justice,
are not physicians’ ethics, but they are more on the societal level. Furthermore, autonomy is more about the virtue of a patient, of being a good
patient, of what we can expect from the patient regarding responsibilities,
and so on. I would be interested to hear whether there is similarly extensive scholarly work on that aspect as well.
Also, I think we would not call the 12 principles presented by Sheikh
Abu Ghuddah a common morality but rather a particular morality. As
Dr. Beauchamp would say, there is the common morality, which is the
universal principles shared by all of us, and there are particular moralities
that can be plural and different.
Hassan Chamsi-Pasha
I will comment very quickly on the issue of certification and degrees. It
seems that very often the ministry of health in some Arab country,
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especially in the Gulf, discovers individuals pretending to be doctors who
have presented forged degrees. I think this is what Sheikh Abu Ghuddah
meant in his paper when he highlighted this as a fundamental ethical issue.
Alternatively, some doctors do have proper medical certification but
occasionally practice outside of their specialization(s). Although this may
be a technical aspect, it also has a large ethical element to it. Take as an
example an individual with proper certification to perform general surgery.
It is allowed for him to perform some types of orthopedic surgery, for
example, because it falls within the umbrella of general surgery. However,
there are other types of orthopedic surgery that he is not allowed to perform
because of their professional requirements. This is how an ethical issue
intersects with professional and technical issues.
Mohammed Ghaly
Do you think this falls under the scope of God-consciousness?
Hassan Chamsi-Pasha
We may place it within the scope of God-consciousness, but it is certainly
within the scope of honesty.
Mohammed Ali Al-Bar
I will make some brief comments. First, I would like to clarify that
Al-Razi lived about a hundred or more years before Al-Ruhawi; there are
often misconceptions about this. Second, scholars are unsure as to whether
Al-Ruhawi was a Muslim, Christian, or Jew. Most opinions indicate he
was a Christian. He might have converted to Islam later as many nonMuslim doctors did at the time, but we do not know for sure. In the Arab
medical legacy, it is difficult to distinguish between doctors who were
Muslim and those who were Christian. They used many of the same
phrases, such as, “praise be to God” and, “blessings be upon the messengers of God,” and so forth. The Islamic civilization was inclusive of all,
and the language was shared among all.
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Do you see this as an indicator of the universality of what was written in
that time period?
Mohammed Ali Al-Bar
Yes. There was a culture within the Islamic civilization in which everyone
spoke a common language, so distinguishing between members of different religions was difficult. Even their names were very similar. Names
such as Abu Ali, Abu Al-Hassan, and Hebatullah may seem to belong to a
Muslim and yet we discover that a person with such a name is Christian
or Jewish. This similarity extended to writing styles, appearance, attire,
and other areas. So this gives us insights into the civilizational dimension
of this period of time.
Throughout history and across civilizations, medical practice has
been founded on the two ethical principles of doing good and preventing
harm. The physician was to treat his patients as a father would treat his
children. Islam introduced the emphasis on the principle of justice in the
physician’s practice of medicine and in the distribution of services.
The principle of autonomy was also alluded to in Islam during its very
early stages. Muslim jurists wrote about the topic about 1,200 years ago.
They introduced two conditions that needed to be met. First, an individual
must seek the permission of the concerned authorities to become a doctor
and practice medicine. Second, the patient or the guardian of the patient
must grant the doctor permission to treat the patient. A doctor who treats
a patient without meeting these two conditions could be penalized and
potentially prevented from practicing even if he made no medical mistakes. What is new to us and what has developed only more recently is the
notion that the patient should have all the relevant information when he or
she consents. This is called informed consent. Other than that, the idea of
consent was there, and in Islam even veterinarians were not allowed to
treat an animal without the consent of the animal’s owner.
Therefore, there were two principles in the history of Islamic medicine that are worth mentioning. The first is justice and the equal distribution of services. The caliph would send medical care to even the most
remote areas and even to prisons. This was not included in Hippocratic
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Script of Oral Discussions (Day 1, Session 2) 251
medicine. The second is the freedom of the patient to accept or refuse
treatment. The Prophet (PBUH) rebuked his companions when they forcefed him medicine after he had refused treatment.
We must acknowledge there are differences in certain understandings.
The Islamic civilization’s notion of the patient’s autonomy, for example,
does not reach the excess that is present in the Western understanding.
According to the Western concept, the understanding of the patient’s
autonomy is that it is absolute. This restricts the doctor’s actions to a large
extent. For example, a patient has the right to request from a doctor to
change his gender from male to female, and I do respect this right.
However, as a Muslim doctor, I may not agree with this procedure, and
I have the right to refuse to perform it. In the Western system, the doctor
does have the right to refuse the procedure, but he or she must refer the
patient to another doctor. The same goes in matters of abortion without a
medical reason: although in the Western system a doctor may refuse to
perform this procedure, he or she must refer the patient to another doctor
who will.
The question is, to what extent does the patient have the freedom to
do as he or she chooses? If a patient is taking drugs or abusing alcohol, to
what extent am I as a doctor allowed to tell the patient that this is right or
wrong? The term that is often used in these situations is “paternalism.”
This was previously understood as wanting the best for someone or trying
to save a person from harm. Now it is considered an insult in the Western
medical context. Of course, I am not saying there is no limit to how much
a father or doctor should advise his child or patient. I am not against the
principle of autonomy. Islam advocates for an individual’s freedom to
choose his or her own religion. We see this in the Qur’anic verse, “There
shall be no compulsion in [acceptance of] the religion…” (Qur’an 2:256).
By extension, there should be no compulsion in medical care. However,
the aversion to the concept of paternalism should not reach to the point
that it almost becomes a crime in and of itself. Nevertheless, the differences I have outlined lie in the details, not in the foundational principle.
Tariq Ramadan
I have a question regarding Dr. Bredenoord’s comment that we are not
talking about ethics of the physician but rather about the ethics of
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medicine more generally. Does it suffice for us to simply mention the
higher objectives (maqāṣid) of Sharia and the necessities (ḍarūrīyāt)
among them? Or is there more to be explained? For example, when you
talk about behavior (sulūkīyāt), the last point talks about equality
(musāwāh). Equality could mean justice (‘adl). Where do we draw the
line of autonomy or independence? These are important matters, and there
are never responses. We always go back to the higher objectives of Sharia
and the necessities alone. Does this suffice as a response to what comes
from the West? Can we offer something from Islam and its understandings, principles, and objectives?
Mohammed Ghaly
Dr. Ramadan, do you mean that we should expand the understanding of the
higher objectives of Sharia so they may be used in the scope of medicine?
Tariq Ramadan
No, I do not mean expansion in this way. I mean we need to be more precise about our goals. Sheikh Raissouni mentioned three of the five objectives of Sharia (the preservation of life, offspring, and the intellect) that he
thought have a connection to medicine. In my opinion, it is not enough to
simply repeat these words [i.e. these higher objectives] without going
back to some of the principles and really talking about their meanings. We
need to really talk about autonomy and other principles and how they
relate to practices on the ground (sulūkīyāt). Can these points be considered in the Islamic response?
Mohammed Ghaly
So the question is, can we rely exclusively on the higher objectives of
Sharia to create the governing principles in medicine?
Abdul Sattar Abu Ghuddah
The higher objectives of Sharia are high principles from which practical
applications are derived. We cannot confine them to just the three that
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Script of Oral Discussions (Day 1, Session 2) 253
were mentioned — preserving life, the intellect, and offspring — even
though they are the most important and relevant to medicine. We can also
include other higher objectives like preserving religion or preserving
wealth. These are all principles to pay attention to when considering relevant practical applications. Some scholars have also added other objectives to these original five, both long ago and in modern times. For
example, preserving the environment was recently added.
We do not limit ourselves to the higher objectives of Sharia alone;
rather, they direct our interpretations of texts so we do not go outside of
them when engaging in independent legal reasoning (ijtihād) and so we
do not cling to literal interpretations of texts. It seems to me that the higher
objectives of Sharia are not these five alone. We may add to them anything that realizes sound behavior and the safety of human beings, societies, and the environment. Dr. Al-Najjar wrote a book about this, in which
he added several other higher objectives and provided evidence for these
additions. The higher objectives of Sharia that we have been talking about
were articulated by Imam Al-Haramayn and then Al-Ghazali, but their
contributions were only the beginning, and we are of course allowed to
add to them.
When I used the phrase “the governing principles for ethics,” I wanted
to highlight two issues. First, when talking about governing principles we
must clarify what is being governed, which in this case are the ethics.
Some principles are indeed governing, and I started with them: the need
for acquiring medical experience, conforming to standard occupational
principles, respecting specializations, abiding by rules and regulations,
and obtaining knowledge of Sharia rulings. These five are governing principles for all the actions the physician does. After this come ethical values
such as God-consciousness (taqwá), excellence (iḥsān), sincerity (ikhlāṣ),
honesty (ṣidq), trustworthiness (amānah), humility (tawāḍu‘), and compassion (rifq).
It is worth mentioning that compassion includes mercy. The Prophet
(PBUH) said, “Indeed, compassion is not in something except that it beautifies it, and compassion is not removed from anything except that it blemishes it.”1 In fact, the physician has been called rafīq (the compassionate
one). Needless to say, I could not talk about the governing principles
1
Narrated by Muslim (No. 2594).
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without explaining in detail what they govern, and I could not talk about
ethics without explaining the higher principles from which those ethics are
derived.
As for focusing on the ethics of the physician, this is because the
patient submits to the physician. Sufis or ascetics say that a disciple before
his or her teacher should be like a patient in the presence of his or her
doctor, doing as the teacher or doctor wishes. Therefore, we do not need
ethics for the patient, except in some rare cases. Some patients behave
poorly towards their doctors because of arrogance, pride about their
wealth, or social standing. A poet once wrote,
Indeed neither the teacher nor the doctor offers their counsel
If not respected or given due credit,
So bear with your illness if you degrade its healer
And bear with your ignorance if you forsake a teacher.
So a student and a patient should behave appropriately with their
teacher and doctor if they seek benefit from them. The issue of confidentiality is an example of a two-way ethical expectation: the patient should
provide the doctor with all relevant information so the doctor has a complete picture, while the doctor should not divulge information about the
patient outside the examination room. Other examples of ethical values
that are expected of both parties are God-consciousness and humility.
In regards to the four principles, I think they are included within the
ethics that have been mentioned in my chapter and in the chapters of my
colleagues but perhaps with different names. For example, being compassionate is the same as showing mercy. The same applies to the terms
autonomy and consent. Likewise, enjoining what is good and refraining
from harmful deeds are different names that can have similar meanings.
The related concept of iḥsān (excellence) exists in the Qur’an and the
Prophetic tradition.
Annelien Bredenoord
I am thinking about your last comment that you recognize the four principles of bioethics from Islamic ethics. You say that they are the same but that
you use different names. My question is, are these four principles enough?
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Is everything confined to these four principles, or do we need to have more?
Because Beauchamp and Childress argue that the four are enough.
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Abdul Sattar Abu Ghuddah
These four principles are what we would call innate principles (dhātīyah)
[i.e. principles innate to a human being]. What we need to add are acquired
principles such as God-consciousness, which involves vigilance and selfmonitoring and is not captured by the four principles. We also have to add
humility, which is not included in the four principles. Sometimes when
doctors excel in their work, they may become arrogant and stop respecting
other specializations. Doctors must also be both conscious and fearful of
God or, if they do not believe in God, at least fear their reputation among
other people. Trustworthiness (amānah) is also not included in the four
principles. So I would say the four principles can be considered seeds for
the universal principles, but we need to add to the set of four principles
from the Islamic perspective what would complete it and increase it in
applicability.
Jasser Auda
I would like to clarify that Dr. Abu Ghuddah is talking about the doctor’s
ethics. He is not talking about legislation, policy, or — in your words —
something related to the society. The realm of society or law is the Islamic
law or Sharia, and that realm is directly induced from the [religious] texts
rather than something that is tied to or based on the ethics that you are talking about. So it seems that the ethics in this sense is virtues and morals
rather than law.
Annelien Bredenoord
As I said before, Islamic medical ethics seems to focus exclusively on
the ethics of the doctor. I think there is a big difference between it and
Western bioethics, which is an ethics of the patient as well as an ethics of
how medicine is distributed in society, which is related more to policy. If
it is exclusively an ethics of what the professional is doing, then there
might be difficulties in stating some universal principles.
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Tariq Ramadan
I think we are touching upon something essential. This is why I wanted
Dr. Bredenoord to be quite clear on her understanding of what is being
said. She talked about the four principles as principles for the society. The
question Sheikh Al-Qaradaghi raised was exactly in light of the four principles: Do we have something in Islam to contribute to that field, not only
for the doctor but also for the society? Sheikh Abu Ghuddah said he does
not have a problem with the four principles but rather we have a problem
of wording and also that maybe other aspects are missing, such as Godconsciousness. In this context he is using the term God-consciousness not
only in reference to God but also in terms of one’s consciousness or selfconscience as a doctor or as a human being. When you listen to this,
Dr. Bredenoord, do you think we are talking about something different, or
do you find that there is common ground beyond the words?
Annelien Bredenoord
There is common ground. I understood it differently, but this helped to
clarify. The interesting point of discussion is whether the four principles
are necessary and sufficient or whether they need elaboration and even
expansion.
Tariq Ramadan
Sheikh Abu Ghuddah argues that they are not enough. He argues that all
the principles might amount to nothing if there is no conscience as an
integral part of the whole process. Do you agree with this, or are we talking about different issues?
Annelien Bredenoord
In my opinion, the concept of consciousness or even self-consciousness is
a part of autonomy. Autonomy is not only concerned with the patient’s
autonomy but also with the physician’s autonomy. Autonomy is understood in many different ways. In fact, there are bookshelves full of books
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written by philosophers about the concept of autonomy, so it is a difficulty
that we have different interpretations of autonomy. Taking a more rich
interpretation, for example that of Isaiah Berlin, would give more positive
accounts of autonomy. They are about consciousness, self-consciousness,
authenticity, and taking responsibility. I think this concept may be part of
our concept of autonomy. It might be that you think it is not the same or
it is not sufficient.
Ali Al-Qaradaghi
Both my commentary and Sheikh Abu Ghuddah’s research indicate that
we accept these four principles but maintain that some principles may
need to be added. I have said before that Islam includes practical ethical
principles that can be adopted by all of humanity, including non-Muslims
and non-Christians. This is because we have scriptures indicating that
Islam was sent as a healing for all people. I was in France once with a
group of scholars, and the French Minister of Economy asked us, “Do you
Muslim religious scholars want, through [achieving] an Islamic economy,
for everyone to be Muslim?” I answered, “Of course not,” and explained
that we want mercy for all of humanity and that this can be of benefit to
everyone. Ultimately, everyone takes of it what he or she wills. If people
want to benefit they are most welcome to do so, but it does not mean they
have to be Muslim.
Mohammed Ghaly
I received a question from the audience. Dr. Ramadan asked Sheikh
Raissouni three questions, but Sheikh Raissouni only answered two of
them. The third question was: Is there a difference between the ethics
of the medical profession in general and the ethics of the doctor? If so,
what is it?
Ahmed Raissouni
The physician is the backbone of the medical profession. It is perhaps for
this reason that Sheikh Abu Ghuddah’s paper and mine focused on the
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physician’s practice and behavior as an embodiment of medical practice.
The process of applying the four principles as laws in society is a different
issue. We do not have a problem with applying these four principles to
economics for instance or even to marital issues. They still apply perfectly
well. Where is the singularity of medicine? The singularity of medicine
comes when we address the practice, behavior, ethics, and attitude of the
physician.
I am still unsure as to why these principles are considered specific to
medicine. As I understand it, once these principles are expanded to the
rules, habits, and policies of society, then they are no longer exclusive to
medicine. Justice is required in everything. Similarly, a human being is
entitled to own property and do what he likes with it. This is considered
autonomy. So the way I understood the task at hand was putting our focus
on physicians and other medical professionals like nurses, pharmacists,
etc. According to the way the four principles have been expressed, it
seems they can be expanded to everything in society. My focus was on
doctors because this was the task at hand.
Mohammed Ali Al-Bar
I have a comment in regards to the principle of justice and distributing
medical services. Societies today are complex. The relationship is no
longer only between the doctor and the patient. It has expanded to the
scale of an entire society whose members either receive medical services
or do not. For example, a country like the United States is very advanced
in medical care and possesses excellent hospitals and doctors. Yet there
are some 50 million people who have no medical insurance and do not
have access to medical care. Beauchamp himself admits that in the latest
edition of his book. There are another 30 million who occasionally may
get medical insurance for about 6 months and then spend the following
year or two without any. This means about one-third of the entire population of the United States does not have proper medical insurance.
I will give a simpler example. Malaysia spent $680 per capita on
healthcare in the year 2010 while the United States spent $7,800 per
capita in the same year. That is almost 12 times the amount Malaysia
spends. In comparison though, the mortality rates of children (one of the
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Script of Oral Discussions (Day 1, Session 2) 259
standards for health used by the World Health Organization) in Malaysia
was 3 out of 1,000, and in the United States the rate was about 5.5 out of
1,000 in the same year. In other words, the United States spends 12 times
as much as Malaysia on healthcare and yet by the standards of the World
Health Organization, Malaysia is doing better. Singapore’s mortality rate
of children is 1 out of 1,000, the lowest rate in the world. If we look at
countries in northern Europe like Sweden and Norway, they spend about
one-third of the amount spent by the United States, and their rates are
much better than the United States’. In fact, the United States ranks last
among the 28 industrial countries. The United States ranks below even
Cuba and perhaps ranks around the same level as Sri Lanka with regards
to the large portion of the population without medical insurance.
Therefore, if the principle of justice encompasses all these considerations, then medical care and health issues are no longer about the doctor–
patient relationship but rather address an entire system. This system calls
for comprehensive policies. Despite being the strongest country with
some of the world’s best medical advancements, doctors, and hospitals,
large amounts of money are spent and yet their ranking remains low. This
leads to a clear conclusion, that there is a major flaw in their system. The
expenditure of large sums of money and yet failing to achieve the required
levels of medical care should raise a lot of eyebrows. Clearly, the United
States system needs extensive re-evaluation.
Achieving justice certainly extends beyond the doctor–patient relationship nowadays, and the West is right to consider justice at a broader
societal level with associated political issues. In addition, these are not
issues exclusive to countries like the Netherlands, Britain, or the United
States. The issues of injustice and discrimination from a medical perspective are issues of concern for the global community as a whole. Our colleagues in the West are talking about these issues while we have yet to pay
much attention to them.
Mohammed Ghaly
This is a central point: in Western academic research that addresses
guiding principles of medical ethics, they are not merely concerned with
the doctor–patient relationship. Rather, their focus encompasses the
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distribution of wealth, social justice, and the like. As a result, they lay
down what we could call “fundamental virtues” (ummahāt al-fadā’il)
and “fundamental ethics” (ummahāt al-akhlāq) and then choose the most
appropriate and most cohesive of them with regards to medical matters.
So, it is not about matters specific to the doctor–patient relationship.
Rather, they are more concerned with broad ethics and guiding principles
and then after that they choose what is most relevant with regards to the
problems that exist in medicine. This may be a good discussion point for
us in the future.
Abdul Sattar Abu Ghuddah
It is true that the question of justice was not dealt with elaborately in the
history of Islam. The reason for this is that medical care used to be free of
charge and its costs were covered through endowments (waqf ). Dr. Ahmed
Issa wrote a book on the history of what is called the bīmāristān, which
in Islamic history was a medical city in which people would receive
medical care free of charge. Anyone could visit it and stay as long as he
or she wished. Some people would even choose to remain there after
being treated because there were good meals and other services. So justice
was present automatically because of the system of endowments. There
were no hospitals making profit, fairly or unfairly, from providing medical
care to sick people. It was a comprehensive medical system where medical care and medication was free of charge.
Tariq Ramadan
This is an important point because it is not only related to economy and
justice; it is also associated with culture. I was in Morocco and spoke with
some doctors about issues surrounding cancer. I noticed that when the
doctor would speak to the patient, the entire family would urge the doctor
to remain silent and not disclose information about the patient’s illness to
the patient. This may seem like a detail, but it is actually a crucial point
regarding autonomy and independence of choice. This silence is characteristic of the Arab culture, but it is not correct according to Islam. Surely,
it is not acceptable for a cultural trait to overrule an Islamic principle.
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Script of Oral Discussions (Day 1, Session 2) 261
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Ahmed Raissouni
All in all, if the principle of justice includes issues concerning society, then
it applies to education, employment, transportation, and all areas — not
only medicine. Hence, my question is, why do we call it medical or biomedical ethics? Everything we have been talking about applies to so many
areas of life. If indeed this is our discussion, then let us open the door for
all our morals, values, ethics, principles, priorities, and objectives. In Islam
for instance, things such as justice, freedom of choice, and principles like,
“there should be neither harming nor reciprocating harm” can apply to
everything. Medicine need not be distinguished from other fields in this
regard. Thus, I propose we focus on those things that have a direct application in medicine.
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Governing Principles of Islamic
Ethics in Medicine
Abdul Sattar Abu Ghuddah
Abstract: This chapter is divided into three main sections. In the first
section, the focus is on the great attention paid by Islamic Sharia to ethics as
compared with schools of law from outside the Islamic tradition, which are
usually exclusively concerned with rights and obligations from a judiciary
perspective. The second section is dedicated to terminology and especially
the distinction between two types of ethics, namely philosophy-based
ethics and religion-based ethics. The third section introduces a list of the
basic Islamic ethics in medicine, extracted from Islamic sources including
the Qur’ān, the Sunna, and the writings of early Muslim physicians,
especially the work of Abu Bakr Al-Razi Akhlāq al-tabīb (The Ethics of the
Physician). The list consists of nine items: developing medical experience;
the conformity of the physician’s practices with the professional standards;
having knowledge of Sharia-based rulings related to practicing medicine;
God-consciousness (taqwá) and fear of Him; sincerity and dedication
to work; modesty towards God and compassion towards the patients;
truthfulness and honesty; practicing medicine within the limits of one’s own
medical specializations; and confidentiality.
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In the name of God, the Most Gracious, the Most Merciful.
Praise be to God, The Lord of the worlds, and peace and blessings
be upon our Prophet Muhammad, his household, and his companions.
Our contemporary world has been overwhelmingly immersed in
material matters and preoccupied with worldly discoveries and achievements. There is a dire need to regulate the directions of this rapid progress
through adherence to the ethics and behaviors encompassing each field.
This is especially true for medicine, in light of the significant and widespread impact of its outcomes, be they positive or negative. Hence, it is
necessary to intensify efforts in clarifying the fundamentals of ethics,
linking them to firmly established and constant principles, and avoiding
any influences arising from the potential of commercial gain and/or individual interests. The best principles that one can rely on in this regard are
those embraced by Islam, the religion that God has perfected and through
which He completed His favor to the last nation, enjoining it as a creed,
legislation, and way of life.
God is the Granter of success.
1. Morality in Islamic Sharia
Islamic Sharia enjoys certain unique characteristics that differentiate it
from other schools of law and intellectual doctrines. Among these characteristics is its great concern with moral behaviors, which are ranked in
Islamic Sharia among the legal rulings (al-ahkām al-taklīfīyah) that
include those classified as obligatory, recommended, permissible, reprehensible, and forbidden acts. This concern with moral behaviors is apparent in both general prescriptions and prescriptions specific to different
societal sectors:
• In regards to the general legal prescriptions, we find within the diverse
chapters and topics of Islamic law (fiqh) considerable sections dedicated to issues of moral behavior. For example, in chapters addressing
prohibition and permissibility or those addressing recommended and
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Governing Principles of Islamic Ethics in Medicine 265
abhorred acts, jurists have highlighted numerous moral issues related
to different professions and specializations. These moral issues are
classified in an independent category, as they neither belong to the
prescribed obligations nor to the absolute prohibitions.
• Some authors writing about Islamic law used the title Al-jāmi‘, meaning “the comprehenesive,” for the section dedicated to moral issues and
would place it as the last chapter in juristic manuals. Further, in cases
where the content of this chapter was found to be extensive, it was
developed into a separate, independent book. Examples of these books
include Al-jāmi‘ by the Maliki jurist Ibn Abi Zayd Al-Qayrawani and
Al-jāmi‘ by Ibn Rushd (the grandfather of Averroes), while other
authors used titles that explicitly identified the book’s content such as
Sharia-Based Etiquettes (Al-ādāb al-shar‘īyah) by the Hanbali jurist
Ibn Muflih and the famous Revival of the Islamic Sciences (Ihyā’ ‘ulūm
al-dīn) by Abu Hamid Al-Ghazali.
• In addressing legal prescriptions within professional fields, scholars
from different specializations and disciplines explicitly emphasized the
moral behaviors associated with each field of knowledge and/or specialty. In their books, jurists (fuqahā’) differentiated between legal
rulings, for which the judiciary system can be consulted for guidance,
and those behaviors that are not within the scope of judicial obligation
but rather are subject to a person’s morality. They termed this latter
scope of behaviors “religiosity” (diyānah), meaning those behaviors
that are ordained by religion but remain between God and His servants.
Scholars have authored numerous books on diverse areas of morality
such as the etiquettes (ādāb, singular adab) of learning and teaching,
the etiquettes of the physician, the mufti, the merchant, the traveler,
princes and ministers, the accountant, and the banker, etc. In these
contexts the word ādāb encompasses moralities or behaviors.
It is worth mentioning that, half a century ago, morality was taught to
students as a distinct subject using modern, specialized texts as well as
classical, traditional texts such as summaries of Revival of the Islamic
Sciences. However, this practice was temporarily discontinued until contemporary scholars, once again, revived the focus on behaviors and codes
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of conduct as they recognized the necessity of these issues in achieving
the desired purposes of diverse professions and scientific research, especially within the medical field. This renewed attention was extended to
numerous professions and resulted in the issuance of several professional
protocols particularly for those fields with serious social impacts.
It is also worth noting that law schools are not concerned with — and
even do not acknowledge — moral standpoints. Instead, they focus
exclusively on rights and duties that can be settled through the judiciary
system. As mentioned earlier, jurists, on the other hand, have emphasized
the dual importance of both moral obligations and judicial obligations.
This alienation between laws and moral values is not surprising; rather, it
is quite expected from disciplines and systems that choose to isolate religion from daily life and focus on the utilitarian aim of actions while
excluding the religious perspective on these actions.
On the other hand, Islamic moral values, emerging from the Islamic
belief (the doctrine of human succession on earth, istikhlāf ) and deduced
from the Sharia (the criterion for what is lawful and unlawful), are meant
to achieve superior aims. These superior aims may encompass immediate,
materialistic objectives, or their objective may be retained for the Day of
Judgment. Therefore, values must be observed and maintained even if
they may seem to be detrimental to people, as this perceived detriment is
compensated for through the real benefit of satisfying God’s mandates.
There is insufficient space in this chapter to list the various texts from
the Qur’an and Prophetic Tradition that prove Islam’s great interest in and
concern with moral values as reflected in its approach to God-consciousness
and self-monitoring. God says, “Nay! Man will be a witness against himself [as his body parts (skin, hands, legs, etc.) will speak about his deeds]”
(Qur’an 75:14).
2. Definition of Ethics
Ethics are the foundational principles employed by Sharia, legislation,
and custom (‘urf ) within the regulatory frameworks governing different
specialties and professions. They enjoy a constructive characteristic with
the intention of regulating behavior through identifying right from wrong
across actions, relationships, and policies.
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Governing Principles of Islamic Ethics in Medicine 267
2.1. Definition of Values, Ethical Values, and Behaviors
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Values are those high ideals which direct the mindset and actions of a
person or a society. They are the standards according to which the behaviors of one’s self or others are judged.
2.1.1. Values are categorized as follows
• Intellectual, belief-based, and faith-based values such as the principle
of human succession on earth.
• Ethical values such as truth and honesty. Ethical values are often
referred to in short as “ethics” (akhlāq). Linguistically, the singular
term “ethic/virtue” (khuluq) means habit and instinct. It refers to a
person’s natural disposition or an acquired habit that becomes part of a
person’s nature. Hence, ethics are similar to habits; they are a person’s
second nature.
The difference between intellectual (belief-based) values and ethical
values is at the relative and absolute levels. Belief-based values govern
one’s ideology and behaviors and serve as a reference base for more than
one ethical value. Meanwhile, ethical values are derived from intellectual
values. Each of the two categories has its own particular scope.
Thus, the discipline of ethics, or “morality,” is divided into:
• Philosophical morality, which relies on the mind and absolute philosophical methods in the analysis of moral dilemmas.
• Religious morality, which relies on divine revelation and derives moral
principles from religion, given that the righteous application of religion
ensures striving for good and virtue and avoiding evil and vice. This
is due to God being Al-Latīf (The Subtly Kind), Al-Khabīr (The All
Aware), whose superior knowledge of His creatures outweighs any
inferior theories which may be influenced by a person’s environment
or personal biases.
However, the theological nature of religious morality does not eliminate the role of the mind and human reasoning in the exploration and
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analysis of a practical procedural framework that is committed to good
moral behavior and avoids harmful behavior. Although these explorations
and analyses are means towards an end, they fall under the legal ruling for
objectives (maqāsid) due to their significant impact. This is contingent
upon the means being lawful and that they do not overshadow or neglect
the higher goal under which they are functioning.
Ethical values — just like creed, religious law, and intellectual
values — aim at achieving superior goals. These goals may be accompanied by an immediate materialistic objective, or the objective may be
retained to the Day of Judgment. Therefore, as mentioned earlier, it is
imperative that one strongly commits to ethical values, even if they disadvantage a person, as this is compensated for by the ultimate benefit,
namely the pleasure of God Almighty.
2.1.2. Definition of behaviors
Behaviors are external, visible human actions. Values, whether intellectual
or ethical, are ideals which guide internal aspects of the human being such
as mental reasoning or psychological processes. Behaviors are the external
indicators for a person’s internal attributes. Hence, any consistent behavior
exhibited by a person reflects his or her intellectual and moral values.1
Ethical values (ethics) within the field of medicine have been
addressed from multiple perspectives. Several researchers have identified
certain principles of biomedical ethics that they found to be common
across different regions of the world. These include2:
(i) Respect for human life, dignity, and one’s right to confidentiality.
(ii) Acknowledgment of an individual’s right to choose, whether to
accept or reject treatment.
(iii) Adherence to the principle of providing benefit and preventing harm
to the patient as much as possible.
(iv) Equality and justice in the treatment of all patients.
1
Ashraf Yahya Abdul-Hadi (1995). Moral and Behavioral Aspects of Judgment (Al-jawānib
al-akhlāqīyah wal-sulūkīyah lil-muhāsabah). Cairo: Faculty of Commerce, 3–9, 27–31.
2
Mubarak Sayf Al-Hashimi (n.d.). Muslim Physician Ethics (Akhlāqīyāt al-tabīb al-Muslim),
n.p., 5–6.
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Governing Principles of Islamic Ethics in Medicine 269
The subject of Islamic ethics for physicians has been extensively
addressed within literature dealing with the topic of preserving morality
and public order (al-hisbah).3 One example to cite is the book titled The
Restorer of Favors and the Restrainer of Chastisements (Mu‘īd Al-Ni‘am)4
by Imam Taj Al-Din Al-Subki in which he outlined that a physician has
the right to:
• Provide advice.
• Act with kindness and compassion towards the patient.
• Appropriately allude to the writing of a will if he observes indicators of
the patient’s imminent death.
• Examine sensitive body parts when and as deemed necessary.
• Common blameworthy traits of a physician include:
(a) A lack of understanding of the disease.
(b) Making a hasty diagnosis.
(c) A lack of understanding regarding the patient’s psychological
health.
(d) Practicing medicine prior to completing all requirements and earning the necessary credentials.
(e) Further, he must believe that his medical treatment does not prevent
divine predestination. Rather, he is acting in accordance with
Sharia law and acknowledges that both the disease and cure are
ultimately in the hands of God.
2.2. Properties of Islam, Objectives of Sharia,
and their Relationship to Ethics
One of Islam’s most significant properties is that it is a complete, comprehensive, and balanced religion. This is due to Islam’s divine origin from
God who has created mankind, knows their nature and their dynamic
3
Among them are: Ibn Al-Ukhuwa (1937). Rulings for Controlling Public Market
(Ma‘ālim al-qurbah fī ahkām al-hisbah). Cambridge: Dar Al-Funun; Al-Shayzari (1946).
The Ultimum in the Rulings for Controlling Public-Market (Nihāyat al-rutbah fī halab
al-hisbah). Cairo: Matba‘at Lajnat al-Buhuth wal-Ta’lif wal-Tarjamah wal-Nashr.
4
Taj Al-Din Al-Subki (1993). The Restorer of Favors and the Restrainer of Chastisements
(Mu‘īd al-ni‘am wa-mubīd al-niqam). Cairo: Maktabat Al-Khanji, 133.
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needs, and thus knows best how to fulfill these needs: “Should not He
Who has created know? And He is the Most Kind and Courteous (to His
slaves), All-Aware (of everything)” (Qur’an 67:14).
The objectives of Sharia (maqāsid al-sharī‘ah) arise from the abovementioned properties of Islam. The five objectives of Sharia are preserving religion (dīn), life (nafs), intellect (‘aql), offspring (nasl), and wealth
(māl). Some researchers have also included preservation of the environment as a sixth objective.5
The objective “preservation of life” refers to safeguarding a person’s
right to live. This includes provision of basic necessities for survival and
safety as well as prevention of murder, suicide, or infliction of harm on
oneself or on others.
In order to uphold these objectives, particularly “preservation of
life,” the Sharia outlines well-known checks and balances such as retribution, blood-money (diyah), and disciplinary punishment. Authorized rulers are delegated to make these decisions so as to ensure the protection of
human life from its enemy or from any harm that is a result of aggression,
negligence, or malpractice in a profession concerned with the well-being
of the body.
Following this, jurists, through a process of deduction from legal
texts, formulated numerous legal principles (rules) to address the field
of ethics.6
3. Types of Medical Ethics
The categories of medical ethics vary according to origin and nature as
follows:
• Vocational ethics, those specific to the practice of medicine as a
profession.
• Religio-legal ethics.
• Professional ethics related to medical licensing and certification.
5
See Abdul-Majid Al-Najjar (2006). The Objectives of Sharia, with New Dimensions
(Maqāsid al-sharī‘ah bi-ab‘ād jadīdah). Beirut: Dar Al-gharb Al-Islami, 207.
6
See Abdul Sattar Abu Ghuddah (1982). “Al-mabādi’ al-shar‘īyah lil-tatbīb” (Buhūth fī
al-fiqh al-tibbī). Second International Conference on Islamic Medicine: Islamic Medical
Organization, Kuwait.
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Governing Principles of Islamic Ethics in Medicine 271
This chapter will address the second category despite the fact that
some of these ethics arose prior to the advent of Islam while others
emerged from the West with the introduction of professional protocols and
codes of conduct.
The focus in this context will be limited to that which has relevance
to Sharia-based religioethical character, directly or indirectly, given that
wisdom is the believer’s stray camel that he is always searching for
(al-hikmah dāllat al-mu’min) wherever he finds it, it becomes his.
Common ethics, such as absolute Islamic ethics, shall be presented
through both classical literature that is based on legal texts from the Qur’an
and Prophetic Tradition as well as other writings which cannot be alleged
to have been extracted from Western literature. One example of these writings is the book Physician Ethics (Akhlāq al-tabīb) by Abu Bakr Al-Razi
which, as acknowledged by several impartial Western scholars, preceded
all Western writings.7
4. Islamic Ethics in Medicine
4.1. Acquiring Medical Experience
Any medical practitioner must obtain sufficient theoretical knowledge and
practical experience in his field. In addition, he must constantly remain
informed of the latest advances and discoveries within the various medical
fields so as to ensure that his treatment is consistent with the best and latest medical discoveries, theories, and cures.8 In a situation in which two
physicians were recommended to the Prophet Muhammad — peace and
blessings of God be upon him (PBUH) — to cure a patient, he asked,
“Which one of you is more skillful?”9 Also, as narrated in another hadith,
the Prophet Muhammad (PBUH) said, “Anyone who practices medicine
when he is not recognized as a practitioner will be held responsible.”10
7
See the introduction of Al-Razi (1980). The edited version of Physician Ethics (Akhlāq
al-tabīb) Ed. ‘Abdul-Latif Muhammad Al-‘Abd. Beirut: al-Maktabah al-‘Asriyah.
8
Yusuf Abdullah Al-Turki (n.d.). Muslim Physician: Significance and Attributes (Al-tabīb
al-muslim: tamayyuz wa-simāt), n.p.; Al-Razi (1980), op. cit.
9
Quoted by Malik in Al-muwatta’, vol. 4, 328.
10
Narrated by Abu-Dawud in Al-dīyāt, no. 4586; Al-Nasa’i in Al-qasāmah , no. 4830; Ibn
Majah in Al-tibb, no. 3466; and Al-Hakim in Al-mustadrak, vol. 4, p. 236.
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Abu Bakr Al-Razi said, “Know that thieves and bandits are better than
those who pretend to be physicians because the latter steal money and
may even take lives, and they often do this to good humans. They do all
this just so people would say, ‘This person is a reliable reference in
medicine.’ However, if they had stopped doing this, it would have been
better for their lifer and afterlife. It is very dangerous to treat humans
without knowledge or to give orders and prohibitions without insight.”11
Today, medical degrees and licenses are necessary conditions for the
practice of medicine. Previously, the chief physician in major renowned
hospitals (bīmāristānāt) was responsible for issuing medical licenses.12
Abu Bakr Al-Razi, and of course Galen and Hippocrates before him,
condemn those who claim to have medical knowledge merely through
experimenting on patients. Al-Razi says, “Neglect what the ignorant say
when they claim that someone is skillful only by means experimentation.
This never happens even if he lives the longest life. If such a person gives
effective treatment, it is just good luck (coincidence). The best among
those who do not study the foundations of their fields are those who read
books and use treatments therein while not knowing that things included
in books are not meant to be used in and of themselves but rather are
essays written to be guiding and teaching.” He then quoted from Galen
that, “I prevent all those who consult me in medicine from undergoing
medical treatment that is still in the phase of experimentation.”13
4.2. Conformity with Standard Vocational Principles
In exercising his profession, the physician must uphold standard vocational principles. Given that he is dealing with the human body, if his aim
11
Al-Razi (1980), op. cit., p. 81. He listed some of his observations about those who
pretend to be doctors.
12
Ali Al-Muhammadi and Ali Al-Qaradaghi (1980). Jurisprudence of Contemporary
Medical Issues (Al-qadāyā al-tibbīyah al-mu‘āsirah). Beirut: Dar Al-Basha’ir Al-Islamiyah,
110. Also see Ahmad ‘Isa (1938). The History of the Bimaristans in Islam (Tārīkh
al-bīmāristānāt fī al-Islām). Damascus: Jam‘iyyat al-Tamaddun al-Islami.
13
Al-Razi (1980), op. cit., 77.
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Governing Principles of Islamic Ethics in Medicine 273
is not to cure, his actions would be deemed a crime or an act of aggression
against another person’s soul, limbs, or organs.
Arising from this premise, jurists established certain conditions that
serve to regulate the physician’s liability in circumstances when treatment
leads to harmful outcomes. Among these conditions is the physician’s
compliance with standard vocational principles acknowledged by medical
sciences and the experts in these sciences. Actions that contradict these
principles are religiously and legally prohibited, and the physician must
be held accountable for any such violations.
In their justification for regulating the burden of liability in professional practice, jurists explained that the purpose of the physician’s action
is to cure, not harm. The evidence indicating this purpose is conformity
with the recognized principles and standards within the profession.
4.3. Sharia-based Knowledge of Rulings Related
to the Medical Practice
Physicians must be fully aware and knowledgeable of all legal rulings
associated with the practice of medicine. This is considered to be binding
on every physician (fard ‘ayn) — and not a collective obligation (fard
kifāyah) — as stated by Abu Hamid Al-Ghazali in his identification of
individual duties and obligations. Al-Ghazali did not limit personal
obligations to prayer, fasting, almsgiving (zakāh), and pilgrimage (hajj);
he also included any necessary type of knowledge that professions may
require. Professionals are obligated to exert all efforts in becoming knowledgeable about legal requirements and rulings within their fields and
should not claim that this responsibility falls exclusively on jurists. This
is particularly critical in situations when there is insufficient time to
inquire and obtain a jurist’s opinion.
This legal knowledge protects both the physician and his patients
from any possible errors that they may fall into. In addition, such knowledge may benefit the physician by enabling him to invest his medical
practice in inviting people to get closer to God: “…So ask the people of
the Reminder [Scriptures — the Tawrāt (Torah), the Injīl (Gospel)] if you
do not know” (Qur’an 21:7).
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Some researchers have put forth a suggestion of assigning one or
more jurists to individual hospitals so as to guide patients in jurisprudential rulings regarding their medical circumstances. Alternatively, hospitals
could coordinate with religious institutions that may be contacted and
referred to when needed.
4.4. God-Consciousness (taqwá) and Watchful Contemplation
(murāqabah) of God
Linguistically, taqwá in Arabic is the protecting shield between you and
what you have fear of. In the Islamic tradition, it is the fear of God which
is reflected through a Muslim’s compliance with His orders and abstinence from His prohibitions. Taqwá (God-consciousness) is the approach
that enables individuals to make the best decisions and maintain integrity in their actions: “O you who believe! If you have taqwá towards
God, He will grant you furqān [(a criterion to judge between right
and wrong), or (makhraj, i.e. a way for you to get out from every difficulty)]…” (Qur’an 8:29).
God-consciousness prevents the physician from committing any
immoral actions and induces him to comply with legal rulings in his practice. Furthermore, if the physician is consciously aware of being seen by
God while treating his patient, this will protect him from falling into
negligence or taking advantage of the patient’s weakness and submission
to his doctor. God-consciousness and engaging in mindful contemplation
of God consequently lead the physician to hold himself accountable
before being judged by external authorities, not mentioning that it is far
more effective given that self-monitoring encompasses all mistakes, even
those that may not have been discovered. God says, “Nay! Man will be a
witness against himself” (Qur’an 75:14) and, “…And God is Ever a
Watcher over all things” (Qur’an 33:52).
It was narrated that the second caliph, ‘Umar, may God be pleased
with him, said, “Hold yourselves accountable [in this life] before you are
held accountable [before God in the Hereafter]. Also, critically evaluate
your work before it gets evaluated.”14
14
Narrated by Ibn Abi Shiba in Al-musannif in the book Al-Zuhd, vol. 7, 96.
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Governing Principles of Islamic Ethics in Medicine 275
Some researchers of professional ethics have attributed all morals and
behaviors required in the different professions — including medicine — to
this concept of God-consciousness. They argue that it establishes an attitude of self-monitoring that, in turn, leads to a voluntary commitment on
the individual’s part to ensure that his actions and performance are in
alignment with Sharia. Thus, one will be characterized with personal
reproach in case of negligence of obligations or in case of ignorance of
legal rulings associated with medical principles, ethics, and practice.15
4.5. Sincerity in Work
Al-Razi agreed with the following quote from Galen:
The physician must be sincere to God. He must lower his gaze when he
approaches beautiful women and should avoid touching their bodies. In
the process of treating them, he should examine only the diseased area
of their body.16 The physician must be dedicated to his work, respect the
rights of others, and pursue excellence and innovation in all his efforts.17
Dedication to work requires that the physician abstain from practicing
any other profession that may conflict with his medical practice, such as
pharmacy, through which the physician may prescribe medication to his
patients in order to receive undue profit.
4.6. Modesty towards God and Compassion for Patients
God says, “And by the Mercy of God, you dealt with them gently. And
had you been severe and harsh-hearted, they would have broken away
from about you…” (Qur’an 3:159). It is related that Prophet Muhammad
(PBUH) said, “God has revealed to me that you must be humble, so that
no one oppresses another and boasts over another.”18
15
Mas’ūlīyat al-murāji‘ fī al-sharī‘ah, p. 123.
Al-Razi (1980), op. cit., 28–29.
17
Ali Al-Muhammadi and Ali Al-Qaradaghi (2006), op. cit., p. 110. For more information,
see the International Islamic Fiqh Academy Journal, 3(8): 407–410; and Ahmad Kan‘an
(2006). Medical Jurisprudential Encyclopedia. Beirut: Dar al-Nafa‘is: 651–655.
18
Narrated by Muslim in the book Al-jannah wa-sifat na‘īmihā wa-ahlihā, no. 2865; AbuDawud in the book Al-adab, no. 4895; Ibn Majah in the book Al-zuhd, no. 4179, on the
authority of ‘Iyad bin Himar.
16
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Modesty diverts the physician from arrogance and self-adulation. It
enjoins him to thank God for the gift of knowledge through which he is
able to benefit others and gain God’s pleasure. This quality ensures the
physician’s acknowledgement that the cure is ultimately in the hands of
God and that his work or intelligence is but a means intended to execute
God’s will.
Al-Razi also transmitted the following quote from Galen: “I saw some
physicians who, once they visit with kings and gain their pleasure, become
arrogant with the public, deny them cure, and interact with them in an
aggressive manner. Thus, these persons are deprived from blessings.”
Following this, Al-Razi added, “Know that modesty in this profession
(medicine) is an ornate and beautiful quality that does not imply weakness
or humiliation. Modesty is practiced through eloquence, compassion, and
avoiding vulgarity and insolence towards others… I saw some physicians
who, in instances when they managed to treat a patient from a dangerous
ailment, became arrogant and boastful. These persons will never be
successful.”19
Modesty requires reliance on and trust in God (tawakkul) in addition to the belief that God is the source of the cure and any efforts
exerted by the physician are only a means through which God provides
the cure.
Abu Bakr Al-Razi said, “The physician must rely on God in all his
actions and expect the cure from Him. He must never presume that his
efforts and abilities are the source of the cure, otherwise, God shall prevent him from arriving at the cure.”20
4.7. Truthfulness (ṣidq) and Trustworthiness (amānah)
Truthfulness (sidq) requires the correct explanation of a disease’s complications so that the patient, or his relatives, can make the right decision
regarding the acceptance or rejection of treatment. If the patient discovers
that the physician is lying, the doctor will lose credibility and the patient
will doubt the physician’s knowledge, experience, and reports.
19
20
Al-Razi (1980), op. cit., 36, 38.
Ibid., 37.
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Governing Principles of Islamic Ethics in Medicine 277
The physician must always be truthful about himself and his clinic.
Further, he must never award a medical license or attendance certificate
except to those who deserve it.
However, the manner in which to inform the patient of the truth about
a dangerous illness he is suffering from is a matter of debate. The lawful
approach to informing the patient with the truth is in a manner that does
not exacerbate his illness or cause him to lose hope. Therefore, the physician should abide by the following guidelines:
• Conveying the truth gradually, without implying a sense of finality.
• Communicating through the appropriate person and avoiding direct
statements, particularly if the patient is young, as well as emphasizing
the possibility of being cured, etc.
Trustworthiness (amānah) refers to the conviction that medicine is a
sort of trusteeship and responsibility. Thus, the physician may not refrain
from treating patients, especially if their condition requires urgent intervention. This also entails that the physician must be punctual and immediately show up whenever there is an emergency. In brief, trustworthiness
requires the fulfillment of duty, the treatment of patients, and earnestly
seeking their cure that is to take place by God’s will.
Abu Bakr Al-Razi said, “The physician must provide equal treatment to
the rich and poor; hence, we should follow the approach of Galen the Sage.”21
4.8. Respecting Medical Specializations
The field of medicine includes diverse specializations. The physician
should practice within the limits of his specialization only. However, he
should have basic knowledge of the other branches of medicine so as to
refer the patient to the appropriate specialization whenever needed.
This is particularly important in the area of psychology as stated by Ibn
Al-Qayyim.22
21
Ibid.
Ibn Al-Qayyim (1993). Prophetic Medicine (Al-tibb al-nabawī). Beirut: Dar Maktabat
Al-Hayat: 117.
22
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This moral value also entails that a physician exhibits respect towards
his colleagues of different specializations and refers patients to them without any hesitation or arrogance. He may not insult or humiliate them or
undermine their scientific credibility.
Further, respect for other disciplines includes refraining from the
practice of any specialization that may conflict with the physician’s
medical practice, especially if this may pose a physical or religious risk.
An example of this is a physician issuing legal rulings (fatāwā) to his
patients. Instead, the physician should ask the relevant experts (professionals) within each medical branch or other fields, particularly in issues
of jurisprudence and Sharia rulings.
4.9. Confidentiality
The physician should safeguard secrets that he comes to know because of
the nature of his work. He is not entitled to disclose these secrets except
in special cases regulated by Sharia and professional laws. The physician
may not divulge a patient’s secret, his personal history, or his private relationships which the physician may deduce based on conversations with
the patient. The breaching of confidentiality is considered to be a negative
quality, an abuse of trust, and an action that must be subjected to legal,
professional, and religious accountability.
The physician’s oath, in all its forms, strongly emphasizes the obligation of confidentiality.
It was narrated that the Prophet Muhammad (PBUH) said, “When a
man tells someone something and then departs, it is a trust (amānah).”23
Similarly, a well-known idiom asserts, “Gatherings are characterized by
trustworthiness,”24 [i.e. when people meet in an assembly, they expect
mutual trustworthiness]. Given this significant weight placed on confidentiality within regular circumstances, accordingly, this weight is augmented
under medical circumstances that often require full disclosure by the patient.
Abu Bakr Al-Razi states, “The physician should treat people with
decency, respect them in their absence and safeguard their secrets. Often,
23
24
Narrated by Ahmad in Al-musnad, no. 15062.
Ibid., 14693.
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Governing Principles of Islamic Ethics in Medicine 279
individuals do not share their illness with their core family such as parents
and children, and yet they share this information with their physician out
of necessity.”25
In issues of confidentiality, Al-Razi reproaches patients who withhold
secrets from their physician. He states, “It is a major error to withhold
secrets from a doctor for fear of being blamed. The patient has thus committed two crimes as the doctor will be unable to find the appropriate cure
without full disclosure.”26
See further Appendix A for the resolution of the International Islamic
Fiqh Academy (IIFA) on confidentiality.
4.10. Experimentation Cannot Be Done without Patient Consent
As mentioned earlier in this chapter, patient consent is a condition for the
administration of treatment. Hence, the prescription of any new medication or drug must be approved by both the patient and relevant authorities.
In addition, research regulations must be adhered to when conducting any
experimentation such as gaining patient consent prior to extracting any
sample that exceeds regular requirements.
Consent given by the patient will not be considered if it relates to an
experiment that involves a definite risk, but it will be considered once it
relates to experimenting with medicine whose benefit is likely. This rule
does not apply for patients only but also for those who volunteer to
undergo experiments for trying a new medicine. After getting the official
license, they can give their consent to participate in experimenting a new
medicine as long as it is expected that it will yield benefit. Necessary
precautions should also be taken such that in case the experiment produces side effects, the costs of treating the volunteer should be afforded.
4.11. Abiding by Professional Laws and Regulations
As with all professions, the physician must abide by Sharia and operative
laws in addition to any resolutions and regulatory frameworks stipulated
by relevant authorities as long as they do not conflict with Sharia laws.
25
26
Al-Razi (1980), op cit., 27.
Ibid.
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This also entails cooperation with public health institutions and
authorities when addressing epidemics and other societal health risks.
This falls under the religious obligation of adhering to higher authorities as long as this adherence does not contradict with any Sharia laws.
4.12. Excellence (Iḥsān) in the Sense of Quality and Perfection
There are numerous Sharia laws that emphasize the importance of striving
for excellence in the performance of any work. In the Qur’an, God states,
“Verily, God enjoins justice and excellence (ihsān)” (Qur’an 16:90).
Justice in this context refers to maintaining the rights of all parties.
Excellence, on the other hand, refers to providing the highest quality of
service, above and beyond basic obligations. As narrated in one hadith,
“Verily God has enjoined exclellence (ihsān) in every action…”27 and
another hadith further emphasizes that, “God loves from you that when
you do something, you do it with excellence.”28
The physician must fulfill his commitment to the patient or hospital
in performing a full diagnosis of his patient’s case. He must ensure accuracy through conducting a full review of his patient’s file; otherwise, any
ignorance or negligence of even the slightest details may lead to misdiagnosis. This, in turn, could result in the physician prescribing wrong medications and treatments that may cause harm to the patient. Hence, the
physician must exert sufficient time and effort in diagnosing and treating
his patients, as most medical mistakes occur due to inaccurate examinations and rash actions.
It is worth noting that a large volume of patients neither justifies a
physician’s heedlessness nor excuses imprecision. In cases of imprudent
diagnosis and negligent treatment, the physician must be held legally
liable for any errors and harmful consequences that may have occurred.
In general, the physician must avoid any potential risks associated
with his practice and diligently take all necessary precautions in every
situation.
See Appendix B on Ethics of Biological Scientific Research.
27
28
Narrated by Muslim, no. 1955, on the authority of Shidad bin Aws.
Narrated by Abu Ya‘la in his Musnad, vol. 7, 349.
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Governing Principles of Islamic Ethics in Medicine 281
See Appendix C on The Medical Oath and the Codes of Medical
Ethics.
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5. Breach of Medical Liability (Medical Malpractice)
5.1. Definition of Liability (mas’ūlīyah)
“Liability” in this sense refers to a person’s commitment. Imam Al-Shafi‘i
articulated a synonymous expression using the term ma’khūdhīyah.29
Liability is defined as the commitment made by a person regarding his
ability to perform an assigned task or duty under specific conditions (standards of performance) and being accountable to any breach of this liability
on his part. In a situation of violating professional standards, the physician
is held responsible for any harm he causes the patient as a consequence of
this violation. As narrated by the hadith,30 “Anyone who practices medicine
although he is not recognized as a practitioner will be held accountable.”31
5.2. Medical Malpractice
Imam Abu Hanifa declared that legal restrictions (hajr) must be placed on
the following three types of people:
• An irreverent mufti, who issues excessively lenient fatwas to the extent
that he contradicts Sharia in order to increase worldly gains.
• An ignorant physician, who practices medicine without earning the
required qualifications and training.
• A bankrupt leaser, who deals with people for the purposes of renting
from him but has nothing to rent.32
It is no secret that an unqualified physician has the status of an
ignorant physician, who is inconsiderate in the matter of providing correct
29
Al-Shafi‘i (1990). The Message (Al-risālah). Beirut: Dar Al-Kutub Al-‘Ilmiyah: 20–21.
The source of this hadith has been mentioned earlier.
31
Mahmud Shaltut (n.d.). Al-mas’ūlīyah al-madanīyah wal-jinā‘īyah fī al-sharī‘ah
al-Islāmīyah. Cairo: Azhar University; Husayn Shihatah (n.d.). Al-ittijāhāt al-mu‘āsirah fī
al-murāja‘ah: n.p.
32
Al-Kasani (1950). Al-badā’i‘. Beirut: Dar Al-Kutub Al-‘Ilmiyah: vol. 5, 200.
30
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information. The point here is not — as Hanafi scholars said — that hajr
means halting and invalidating their actions. Rather, the point is preventing them from practicing and dealing with people, and such prevention is
considered an act of enjoining good and forbidding evil since an ignorant
physician corrupts health and wealth. Sharia has ordained the preservation
of health and wealth, by consideration of its objectives, and prohibiting an
ignorant physician from practicing is obligatory on the ruler and everyone
with authority over such matters.
Islamic Sharia prohibits both perpetrating harm and assisting in the
perpetration of harm, and it considers the one who does so as coperpetrator. This includes failing to speak out against harmful acts. God
enjoins, “Help you one another in al-birr (virtue, righteousness) and
al-taqwá (God-consciousness); but do not help one another in sin and
transgression. And fear God. Verily, God is Severe in punishment”
(Qur’an 5:2).
If a physician practices medicine while lacking the adequate training
and experience or failing to abide by professional standards (i.e. practicing without a medical license), he will be liable and must be held accountable for any harm resulting from his error, incompetence, or negligence.
Thus, the physician’s liability is both contractual and criminal. When
dealing with an independent physician, contractual liability means that the
patient is hiring the physician’s medical services and the physician is committed to providing treatment to those who hire him. However, if the
physician works in a hospital, he is contracted by the hospital to provide
specific medical services. Thus, liability shall arise initially against the
hospital, before final settlement with the physician (from the resolution of
IIFA on Liability).
As for criminal liability, in principle the physician should not be liable because he is performing a collective duty (fard kifāyah) and the
Sharia-based rule stipulates, “[Performing] a duty is not conditioned by a
guarantee for safety.” However, because the way in which this duty is to
be performed is the physician’s choice alone — bearing in mind his
extensive power and authority to choose the method of performance
based on his best judgment — it becomes necessary to examine the possibility of the physician’s criminal liability when his work results in
damage. This is because, in this case, the position of the physician is
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Governing Principles of Islamic Ethics in Medicine 283
closer to the possessor of a right rather than someone who is performing
a duty, and the possessor of a right can be held accountable in case he
exceeds his right.
As mentioned earlier, there is unanimous agreement on the exoneration of the physician if he possesses knowledge and experience,
acts in good faith and for the purpose of treatment, adheres to the principles of medical practice, and gains consent from the patient or legal
guardian.33
6. The Sharia-Based Deterrents Concerning the Breach
of Medical Liability
6.1. The Ruler’s Role in Implementing Penalties
Islamic legislation classifies crimes under two categories. The first category is crimes with prescribed penalties, referred to as hudūd. The second
category is crimes with non-prescribed penalties, namely “disciplinary
crimes.” These include all crimes for which a definitive punishment has
not been specified within scriptural sources of legislation. This second
category encompasses all transgressions against God’s rights or human
rights whose penalties have not been divinely ordained. The determination of the appropriate punishments for these crimes was left, by the Wise
Legislator, to the discretion of the ruler so as to ensure consideration for
the conditions of time and place. This reinforces the comprehensive
nature of Sharia and its assured compatibility with the ongoing changes
and developments of life.34
Professional malpractice that results in apparent or hidden damage,
especially amongst professions based on trust and honesty, poses a
threat to public interest, or as coined by jurists, “right of God,” which
in this context denotes the right of society. Jurists affirmed that the
33
Abdul Sattar Abu Ghuddah (n.d.). Physician’s Jurisprudence and Etiquettes (Fiqh
al-tabīb wa-adabuh). Kuwait: University of Kuwait: 10.
34
Ibn Taymiyah (1992). Al-siyāsah al-shar‘īyah, Beirut: Dar Al-Fikr Al-Lubnani: 120–
133; Ibn ‘Abidin (1889). Hāshīyat Ibn ‘Abdīn, Istanbul: Dar al-Tiba‘ah al-‘Amirah:
vol. 3, 184; Abdul-Qadir Auda (2001). Al-tashrī‘ al-jinā’ī fī al-Islām. Cairo: Dar alShuruq: vol. 1, 63, 704.
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harmful impact of malpractice must be eliminated in accordance with
the Sharia-based rule stating, “There should be neither harming nor
reciprocating harm,” as quoted in the hadith narrated by Ibn Majah.35
The responsibility of ensuring accountability for malpractice falls upon
the ruler. Further, imposed punishments should not be limited to the request
put forth by the victims. This is because the harmful impact of malpractice
extends to all people even if the direct victim was only one individual. A
jurisprudential rule states that “Anyone who commits an offense for which
there is no prescribed penalty (hadd), s/he may be liable to a discretionary
punishment (ta‘zīr).”36 In regards to forms of punishment, Sharia law has
defined physically deterring corporeal sanctions as well as sanctions
restricting freedom (jail), which Ibn Al-Qayyim explains as, “This does not
include restricting the person and preventing him from free action.”37
Sharia law also recognizes financial sanctions, such as the confiscation of
money to the State’s treasury, or sanctions that discredit the perpetrator in
order to condemn this action and warn people against committing it.
Sanctions may also be in the form of excommunication including revoking
the physician’s license to practice and all associated benefits. In some
cases, sanctions may require psychological retribution through issuing
advice, notices, warnings, or even ostracizing (boycotting, etc.) him.
More Readings
Al-Razi (1977). Ethics of the physician (Akhlāqīyāt al-tabīb), Dr. Abdul-Latif
Al-Abd (ed.). Al-Turath.
Muhammad Lutfi Al-Sabbagh and Al-Maktab Al-Islami (1988). Ethics of the
physician (Akhlāq al-tabīb).
Dr. Ali Al-Jaffal. Ethics and liability of the physician and the rulings related to
some of those who have incurable diseases (Akhlāq al-tabīb wa damānuh
wal-ahkām al-muta‘alliqah bi-ba‘d dhawī al-amrād al-musta‘siyah).
International Islamic Fiqh Academy Journal 8(3): 363–406.
35
Narrated by Ibn Majah in Al-Ahkām, no. 2340.
Mahmud Hamza (1880). Al-fawā’id al-bahīyah fī al-qawā‘id, Damascus: Matba‘at
Habib Khalid: 134.
37
Ibn Al-Qayyim (1899). Al-turuq al-hukmīyah. Cairo: Matba‘at Al-Adab: 102.
36
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Governing Principles of Islamic Ethics in Medicine 285
Mubarak bin Sayf Al-Hashimi. Ethics of the Muslim physician (Akhlāqīyāt
al-tabīb al-muslim). Available online via www.scribd.com (retrieved 18
October 2014).
Dr. Muhammad Sulayman Al-Ashqar. Revealing the secrets in Islamic Sharia
(Ifshā’ al-sirr fī al-sharī‘ah al-Islāmīyah), in Al-ru’yah al-Islāmīyah li ba‘d
al-mumārasāt al-tibbīyah, 86–106.
WHO. Electronic code of health ethics (Dustūr akhlāqīyāt al-sihha ). Middle East
Regional Office.
Dr. Ahmad Raja’i Al-Jindi. Medical profession secret between confidentiality and
publicity (Sirr al-mihnah al-tibbīyah bayn al-kitmān wal-‘alānīyah).
Dr. Amin As‘ad Khayr Allah (1946). Arabic medicine (Al-tibb al-‘arabī). Beirut:
Catholic Press.
Dr. Zuhayr Ahmad Al-Suba‘i and Dr. Muhammad Ali Al-Bar. The physician:
Etiquettes and jurisprudence (Al-tabīb, adabuh wa fiqhuh). Dar Al-Qalam.
Dr. Yusuf Abdullah Al-Turki. Muslim physician: Distinguishing characters (Al-tabīb
al-Muslim: Tamayyuz wa simāt). Dar Al-Watan Publication Press, no date.
Dr. Shawkat Al-Shatti. The Science of medical ethics (‘ilm ādāb al-tibb).
Damascus University Press, no date.
Dr. Abdul Sattar Abu Ghuddah (1981). Physician’s jurisprudence and etiquettes
(Fiqh al-tabīb wa adabuh). Majallat al-Muslim al-mu‘āsir 28: 145–165.
Dr. Ali Al-Qaradaghi, Dr. Ali Al-Muhammadi and Dar Al-Basha’ir (2008).
Jurisprudence of contemporary medical issues (Fiqh al-qadāyā al-tibbīyah
al-mu‘āsirah).
Rulings for controlling public market (Ma‘ālim al-qurbah fī ahkām al-hisbah).
Ibn Al-Ukhuwwah (1938). London, Luzack.
Ahmad Muhammad Kan‘an (2000). Juristic medical encyclopedia (Al-mawsū‘ah
al-tibbīyah al-fiqhīyah). Dar Al-Nafa’is.
WHO. International Islamic Code of Medical and Healthcare Ethics. Middle
East Regional Office.
Al-Shayzari (1981). The ultimum in the rulings for controlling public market
(Nihāyat al-rutbah fī talab al-hisbah). Dar Al-Thaqafa li Al-Tiba‘ah walNashr wal-Tawzi‘.
Kuwait Document on the Islamic Code for the Medical Profession, Kuwait
Islamic Organization for Medical Sciences, 1981.
Appendix A
Below is the resolution no. (79) 10/8 issued by the IIFA addressing the
question of confidentiality in the profession of medicine during their 8th
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conference held during the period 1–7 Muharram, 1414 AH (21–27
June 1993)38:
First: Confidential information is whatever someone tells another with a
request, beforehand or afterwards, to keep it secret. This includes matters
conventionally known to be of a confidential nature, per se, as well as a
person’s private matters or defects which he loathes to make public.
Second: Confidential information is a trust in the hands of the person who
is asked to keep it secret, as enacted by the Islamic Sharia and the ethics
of magnanimity and proper conduct.
Third: The general rule is that divulging confidential information is proscribed and divulging it without a genuine motive warranting it makes the
person liable to punishment from the perspective of Sharia.
Fourth: Secrecy is even more of a duty for individuals working in professions that are adversely affected by indiscretion such as the medical professions. Those in need of advice and assistance usually resort to medical
professionals and communicate to them all (intimate) affairs that may help
them fulfill their vital tasks properly. This may include information one
keeps from all others, including one’s own kin.
Fifth: On exceptional basis, the duty of secrecy is not binding in cases
where keeping the secret may entail damage for the concerned person
greater than the one that ensues from divulging it or when divulging the
secret may entail a benefit that exceeds in importance the risks of keeping
it. Such cases are of two categories.
(a) Cases where the confidential information must be revealed on grounds
of the rationale of committing the lesser evil in order to avoid the
greater one, and the rationale of achieving the public interest which
may entail enduring an unavoidable private harm so as to prevent a
public one. These cases include two types:
• What involves protecting society from harm.
• What involves protecting an individual from harm.
(b) Cases where where the confidential information can be broken:
• To achieve a public interest.
• To prevent a public harm.
38
Translator’s note: this section is taken verbatim from http://islamicstudies.islammessage.
com/Fatwa.aspx?fid=100 (retrieved 25 February 2016).
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Governing Principles of Islamic Ethics in Medicine 287
In all such cases, one should be committed to the objectives and priorities as set out by Sharia in terms of preserving religion, human life, the
intellect, offspring, and wealth.
Sixth: Exceptional cases in which revealing the confidential information
will be permissible or obligatory must be clearly mentioned in the codes
of medical and professional practice. Such cases must be clearly defined
and enumerated along with all the details as to the manner in which the
secret would be divulged, and to whom. The relevant authorities need to
familiarize each and every one with these cases.
Then the IIFA issued a recommendation of incorporating this topic in
the programs and curricula of medical faculties.
Appendix B: Resolution of IIFA no. 161 (10/17)
Concerning Sharia-Based Standards of Conducting
Biomedical Research on Human Subjects
The IIFA, affiliated with the Organization of Islamic Conference (OIC)
holding its 17th session held in Amman (Kingdom of Hashemite Jordan)
from 28th Jumadah-al-Uwla to 2nd Jumadah-al-Akhirah, 1427 Hijri
(24–28 June 2006).
Having reviewed research papers received by the IIFA regarding the
Sharia-based standards of conducting biomedical research on human
subjects as well as the document issued by the Islamic Organization for
Medical Sciences in its seminar held in Kuwait from 29th Shawwal to
2nd Dhul-Qi‘dah 1425 Hijri (11–14 December 2004) concerning
“International Ethical Guidelines for Biomedical Research Involving
Humane Subjects: An Islamic Perspective,” and after hearing relevant discussions, the IIFA has resolved the following:
(a) First: Endorsing the General Principles of the Document
The Academy ensures approving the general principles and foundations
upon which the ethical standards which regulate biomedical research are
based, according to the following:
(i) Respecting individuals and honoring the human being have stronglyrooted, well-established foundations in Islamic Sharia as God says,
“And indeed We have honored the Children of Adam, and We have
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carried them on land and sea, and have provided them with
al-ṭayyibāt (lawful good things), and have preferred them above
many of those whom We have created with a marked preference”
(Qur’an 17:70).
Thus, the autonomy of a person with full competence who volunteers to participate in medical research must be respected. He
must be enabled to choose and take proper decisions with full satisfaction and free will without any compulsion, deception, or
exploitation in accordance with the Sharia-based rule, “No one can
interfere with a right assigned to a human being without his/her
permission.”
Likewise, an incapacitated person or one whose capacity is
incomplete must be protected from injustice that may come even
from his sponsor or guardian. According to a general jurisprudential
rule, “The one whose actions are not legally valid (from a Sharia
perspective) [e.g. a person whose judgment is impaired because of
mental illness] has no say.” Sharia provides for such a person a sponsor or guardian to take care of his affairs in a way that nurtures his
personal interests without acting in an any harmful or potentially
harmful way.
(ii) Achieving interest (maslahah) has its origins in Islamic Sharia by
bringing benefits to and preventing evils from the servants [of God].
In the case of unavoidable evil, it is better to eliminate the bigger evil
by committing the lesser one.
(iii) Justice is the moral commitment to treat everybody in accordance
with what is right and good from a moral perspective. It is to give
each person his/her right, whether the person is male or female.
Justice is an established principle in Islamic Sharia, whose rules have
been laid out by Islam and which Islam has made the foundation and
basis of success and goodness in life.
(iv) Excellence (ihsān): It is mentioned in the most comprehensive verse
in the Noble Qur’an to induce all benefits and prohibit all evils:
Verily, God enjoins al-‘adl (justice) and al-ihsān (excellence), and
giving (help) to kith and kin and forbids al-fahshā’ (i.e. all evil deeds),
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and al-munkar (i.e. all that is prohibited by Islamic law: polytheism of
every kind, disbelief and every kind of evil deeds, etc.), and al-baghi
(i.e. all kinds of oppression), He admonishes you, that you may take
heed (Qur’an 16:90).
(b) Second: Standards of Biomedical Research on Human Subjects
The Academy asserts endorsing the standards of biomedical research on
human subjects that were included in the document referred to in the
introduction of this resolution, recognizing that they organize biomedical
research within the framework of Islamic Sharia principles and provisions. We call for the Islamic Organization for Medical Sciences to hold a
large-scale meeting that includes physicians and jurists to deepen the
knowledge of such standards.
Recommendations:
(i) The Academy recommends to the officials in Islamic countries that
they take concern in supporting research and researchers by allocating sufficient budgets, providing researchers with suitable conditions,
and meeting their scientific and material needs in order to enable
them to dedicate themselves to fulfilling their national duties.
(ii) The Academy recommends to the Islamic countries that they benefit
from Muslim scientists abroad “as they are a great asset to the Muslim
community (ummah).” The Academy recommends that Islamic countries open channels of communication with these scientists and
encourage them to collaborate with their peers in Islamic countries to
establish solid bases for research in Islamic countries.
(iii) The Academy recommends to the Islamic Organization for
Medical Sciences in Kuwait along with the Ministries of Health in
Islamic countries to organize training sessions for those working
in medicine and healthcare sectors regarding medical and healthcare jurisprudence ( fiqh), professional ethics — especially scientific research ethics — and the standards that have been referred
to in this resolution.
God, though, knows best.
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Appendix C: The Medical Oath and the Codes
of Medical Ethics
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C.1. The Medical Oath Drafted by Ibn Abi Usaybi‘ah
A physician named Muwaffaq Al-Din Ahmad bin Al-Qasim, known as Ibn
Abi Usaybi‘ah,39 formulated the following oath:
“I do hereby swear in God, Lord of life and death, Granter of health,
Creator of recovery and every cure, I call upon God’s friends, men and
women, to witness that I will fulfill this oath and condition. I believe that
he who taught me this profession is like a father to me. I should help and
support him from my own money. His children are like my brothers and
sisters. I shall teach them this profession if they need to learn it, without
payment or condition. I shall engage my teacher’s children and my students, to whom I do set this condition, and I do hereby swear by this
medical code in recommendations, sciences, and all what is included in
this profession.
I shall not give lethal medicine if I was asked to do so and will not
advise anybody to do likewise. I shall never carry out an abortion. I shall
keep my action and profession based on charity (zakat) and purification.
I shall never perform surgery for someone who has stones in the bladder
but shall leave this to those specialized in this practice.
I enter all houses for nothing but to help patients. I refrain from all
injustice and intentional corruption. Anything I see during examination of
patients or hear beyond the times of medical examination that should not be
publicly communicated I shall keep confidential and will never disclose.”
C.2. The Medical Oath for the Islamic Organization
for Medical Sciences
The First International Conference of Islamic Medicine established a
code of ethics for the medical profession,40 and it included the following
39
Ibn Abi Usaybi‘ah (1965). The Best Accounts of the Biographies of Physicians (‘Uyūn
Al-anbā’ fī tabaqāt Al-atibbā’). Beirut: Maktabat al-Hayat: 17ff.
40
Researches and works of the First International Conference of Islamic Medicine (1981).
Kuwait: Ministry of Public Health: National Council of Culture, Arts, and Morals: 700;
Also see Kan’an (2006), op. cit., 784–785.
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Governing Principles of Islamic Ethics in Medicine 291
medical oath: “In the name of God, the Most Gracious, the Most
Merciful: I do hereby swear by God the Greatest to regard God in my
profession; to protect human life in all stages and under all circumstances; to do my best to save it from death, illness, pain, and anexiety;
to protect people’s dignity, cover their private parts (‘awrah), keep their
secrets; to be always an instrument of God’s mercy, extending my medical care to close and strange persons, to the righteous and the sinner,
and to friends and enemies; to steadfastly seek knowledge and to use it
for the benefit of humans and not to harm them; to honor my teachers
and teach my juniors; to be brother to every colleague in the medical
profession joined in goodness and God-consciousness; to make my life a
reflection of my faith, both in private and in public and make it pure and
free from any evil that blemishes towards God, His Prophet, and His
Believers. God is witness to what I say.”
C.3. Codes and Agreements of the Medical Profession
The first manifestation of the idea of medical ethics was developed in the
form of “codes” or “documents” that included laws and regulations. Some
of these were just proposals, whereas others assumed formally-approved
and official status. Given the focus of this chapter, below are references to
international documents that are Islamic in nature:
1. International Islamic Code of Medical and Health Ethics
This code was issued by the World Health Organization (WHO) —
Middle East Regional Office. It includes 10 chapters and 108 articles.
2. E-Health Code of Ethics
This code was also issued by the WHO — Middle East Regional
Office. It includes an introduction and definitions followed by detailed
explanations.
3. Islamic Code of Medical Ethics — Kuwait
This code was issued at the First International Conference on Islamic
Medicine held in Kuwait during the period 12–16 December 1981. It
includes 12 chapters. This document focused on the principles of Sharia
as evidenced in Qur’anic verses and hadiths.
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Response by Hassan Chamsi-Pasha
to Abu Ghuddah’s Paper
Hassan Chamsi-Pasha
I read with great interest the paper of Sheikh Abdul Sattar Abu Ghuddah
entitled “The Governing Principles of Islamic Ethics in Medicine.” It is
very well written and reflects the high scholarly standing of Sheikh Abu
Ghuddah.
For several centuries, the Islamic world has witnessed the great
achievements of Muslim physicians in the area of medicine and health
sciences. These advances were not based on technical skill or intellectual
prowess alone. They were equally founded on a clear understanding of
the role of the Muslim physician as derived from Islamic teachings and
philosophy.1
1. Practical Ethics of the Physician (Adab al-ṭabīb)
Sheikh Abu Ghuddah clearly demonstrated the role of Islamic scholars in
laying down the principles of medical ethics and referred to the book of
Abu Bakr Al-Razi entitled Ethics of the Physician (Akhlāq al-ṭabīb) as
1
Abdul Rahman Amine and Ahmed Elkadi (1981). Islamic code of medical professional
ethics. Journal of the Islamic Medical Association of North America 13(July): 108–110.
293
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one of the earliest books in medical ethics, preceding all Western writings
on the subject. In addition, one of the earliest comprehensive works on
medical ethics is entitled Practical Ethics of the Physician (Adab al-ṭabīb)
by Ishaq bin Ali Al-Ruhawi, who lived in the second half of the 9th century C.E. Al-Ruhawi’s Practical Ethics of the Physician was translated to
English by Martin Levy in 1967, and it contains 20 chapters:
(i) The beliefs that a physician should hold and the etiquettes he or
she should abide by to improve his or her soul and moral character.
(ii) The measures that should be taken to maintain a healthy body and
by which a physician should treat his own body and limbs.
(iii) That which a physician should avoid and beware of.
(iv) The recommendations a physician should give to the caregivers of
the patient.
(v) The etiquettes of the patients’ visitors.
(vi) What the physician should examine concerning single and compound medicines and their putrefaction.
(vii) Matters about which a physician should question the patient or the
patient’s caregivers.
(viii) On what healthy and sick people should all think of and believe
about the physician during the times of health and sickness.
(ix) That both the ill and healthy should accept the counsel of the
physician.
(x) The behavior of the patient towards his family and caregivers.
(xi) The behavior of the patient towards his visitors.
(xii) The dignity of the medical profession.
(xiii) That people should respect a physician according to his skill and
that kings and other honorable people should respect him more.
(xiv) On anecdotes that happened to physicians, some of which have
already been mentioned, so that the physician may be forewarned.
Some of these [anecdotes] are entertaining which urge the physician to check the intelligence of his patient so that misconceptions
will not be ascribed to the physician.
(xv) That not everyone may practice the profession of medicine but that
it should only be practiced by those who have a suitable nature and
moral character.
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Response by Hassan Chamsi-Pasha to Abu Ghuddah’s Paper
295
(xvi) Examination of physicians.
(xvii) Ways by which kings can combat corruption among physicians
and can guide all people with regards to how they can get well
through medicine and how this all was in ancient times.
(xviii) The necessity of warning against charlatans who call themselves
physicians and the difference between their deceit and true medical practice.
(xix) Reprehensible habits to which people are accustomed but that may
harm patients and cause physicians to be blamed.
(xx) Matters a physician should be careful about during periods of
health in order to prepare for periods of illness, and also at the time
of youth for the time of old age.2
As the chapter titles illustrate, Practical Ethics of the Physician is not
merely a manual of professional ethics. It also contains important material
about personal health and the relationship between the patient and the
doctor. It even comments on the medical profession itself and how it
relates to the governing authority. This monumental work demonstrates
the complementarity of early medical principles and the moral framework
of the Islamic tradition and culture. Al-Ruhawi’s work attests to the ability
of Islamic thinkers to assimilate different traditions and philosophies in
the Islamic discourse.3
In the first chapter of Practical Ethics of the Physician, Al-Ruhawi
writes about the beliefs a physician should hold and the etiquettes he or
she should follow to better his or her soul and moral character. Al-Ruhawi
describes three beliefs that a physician should hold:
(i) The first thing in which a physician must believe is that every created
being should have a sole Creator who is Omnipotent, Wise and can
perform all deeds wilfully.
2
Martin Levey (1967). Medical ethics of medieval Islam with special reference to
Al-Ruhawi’s ‘practical ethics of the physician.’ Transactions of the American Philosophical
Society 57(3): 1–99.
3
Aasim I. Padela (2007). Islamic medical ethics: A primer. Bioethics 21(3): 169–178.
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(ii) The second article of the physician’s faith is to have true love for
Allah the Sublime and to be devoted to Him with all his reason, soul,
and free will.
(iii) The third article of faith which a physician must possess is that Allah
sent His messengers to mankind in order to teach them what is good
and beneficial since the intellect alone is not sufficient.4
Practical Ethics of the Physician is a beautiful illustration of the fact
that problems of responsibility, ethical dilemmas, and needs of society are
not new to the discipline of medicine. A review of this work makes us
wonder if the physician of today is negligent of his responsibilities
towards current ethical needs.5
2. Preserving Morality and Public Order
(ḥisbah) and Medicine
In his paper, Sheikh Abu Ghuddah alluded to the topic of ḥisbah, and it is
clear from the sources that addressed this topic that practicing medicine
in toto has been subject to strict regulation since the 9th century up until
the introduction of modern systems.
It is stated that when a physician visits a patient he should ask him
about what is not apparent to the senses and what the reasons are for his
health condition. He should then prescribe the appropriate medication and
write it out for the patient’s family or present relatives. The following
morning, the physician should examine the patient, inspect his urine, and
ask the patient about his health condition. Then he should prescribe for
him whatever the condition requires and write a copy for the family.
The same routine should be repeated on the third and fourth days and
so on until the patient recovers or dies. If the patient recovers, the physician should receive due payment. If the patient dies, the patient’s close
relatives should go to the chief physician and submit the copies of the
4
Levey (1967), op cit., 1–99.
Sharif Kaf Al-Ghazal (2004). Medical ethics in Islamic history at a glance. Journal of the
International Society for the History of Islamic Medicine 3(5): 12–13.
5
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prescriptions that the doctor had written for him. If the chief physician
holds that the physician abided by medical standards and was wise in his
decisions without practicing negligence or deficiency therein, then he
should decide that death simply occurred at the termination of the
deceased’s allotted time. However, if the chief physician holds that
the doctor was guilty, then he should ordain that blood money be paid by
the doctor to the deceased’s family because he killed the patient out of
ignorance and negligence.” Through these excellent procedures, it was
made certain that no unqualified individual would intrude on the field of
medicine and that medicine was only practiced by those who were well
versed in its various specializations.6
The ḥisbah also carefully regulated the study of medicine. It determined the topics to be studied by the physician. It also determined the
penalties to be paid by physicians and surgeons in case of negligence or
carelessness resulting in malpractice. For example, those who performed
circumcision were subject to liability if the operation caused the patient
injury or death.7
3. Realistic and Evolving Jurisprudence
in the Islamic Tradition
One of the intriguing aspects about Islam is that it has a realistic jurisprudence that is constantly evolving. This quality has paved the way in recent
decades for the approval of laws pertaining to the field of medical ethics
that address emerging issues in biomedical sciences and technologies.
Muslim scholars have determined a group of fixed Islamic principles
to consider for ethical decision-making. These include: interest (maṣlaḥah),
the principle of “there should be neither harming nor reciprocating harm”
(la ḍarar wa-lā ḍirār), the principle of necessity (ḍarūrah), and the principle of “removal of hardship” (raf‘ al-ḥaraj).8
6
Martin Levey (1963). Fourteenth century Muslim medicine and the Hisba. Medical
History 7(2): 176–182.
7
Ibid.
8
Bager Larijani and Farzaneh Zahedi-Anaraki (2008). Islamic principles and decision
making in bioethics. Nature Genetics 40(2): 123.
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In the case of absolute necessity, where religiously lawful alternatives
do not exist, it becomes possible to suspend the general ruling according
to the jurists’ assessment of the level of necessity. As an example, religious scholars permitted the use of porcine insulin and heart valves from
pigs on the basis of the principle of necessity.9
Recent scientific and technological advances have resulted in a range
of complex issues that have triggered ethical dilemmas for healthcare
professionals regarding patients and society at large.
Responding to this challenge, many religious scholars have concluded
that in situations requiring specialist knowledge (as is the case with the
medical field), decisions and legal rulings should be made based on collective legal reasoning (ijtihād jamā‘ī) and mutual consultation (shūrá).
For the fatwas pertaining to medicine, the bodies exercising collective
legal reasoning should include a large group of scholars and experts from
different disciplines relevant to the issue at hand in order to clarify the
technical aspects related to their specializations.10
4. Confidentiality in the Context of Research
The Tradition of the Prophet (PBUH) incites us to learn and to conduct
medical research. He stated that Allah has made for every disease a cure.
Islam puts emphasis on seeking knowledge and making benefit therefrom.
Islam also urges spreading knowledge and refraining from withholding it;
as the Prophet (PBUH) said, “Whoever withholds knowledge, Allah on
the Day of Judgment will bridle him with a bridle made of fire.”11
Sheikh Abu Ghuddah emphasized the importance of maintaining confidentiality in the context of medical research as well as other fields.
Protecting confidentiality is an essential value necessary in all human
relationships, not only in medical practice and research. Doctor–patient
and researcher–participant relationships are built on trust and recognizing
9
Abdul Rashid Gatrad and Aziz Sheikh (2001). Medical ethics and Islam: Principles and
practice. Archives of Disease in Childhood, 84(1): 72–75.
10
Ibid.
11
Sahīh al-Tirmidhī, No. 2649
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the necessity of not disclosing the patients’ secrets. However, there are
exceptional cases in which secrets may be disclosed when it is necessary
to meet a strong conflicting duty. Confidentiality has received much
importance in Islamic Sharia and has received much interest by Muslim
jurists, as can be seen in their works. There have been some legal rulings
about this issue, and there have been constant efforts by both individuals
and medical organizations to make use of the collective fatwas issued by
institutions that practice collective ijtihad in the context of research.12
12
Giath Alahmad and Kris Dierickx (2012). What do Islamic institutional fatwas say about
medical and research confidentiality and breach of confidentiality? Developing World
Bioethics 12(2): 104–112.
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Script of Oral Discussions
(Day 1, Session 1)
Day 1, Session 1
After Ahmed Raissouni presented his paper, the following discussion
took place.
Mohammed Ghaly
Sheikh Raissouni mentioned two ethics, neither of which falls in the
framework of the four principles. They are God-consciousness (taqwá)
and mercy (raḥmah). Sheikh Raissouni, since you are known to be an
expert on the identification of the higher objectives of Sharia, is it similarly
possible to identify the fundamental ethics (ummahāt al-akhlāq)? How?
Ahmed Raissouni
Regarding the fundamental ethics, we should first look at the Sharia itself,
wherein we find ethics that are very widespread. For example, when it
comes to the issue of mercy, the Prophet (PBUH) said that when he would
lead a prayer that he [originally] intended to prolong, and if he heard an
infant crying, he would shorten the prayer out of consideration for the
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child. The concept of mercy was present with him in his prayer. The
Prophet (PBUH) recommended to those leading prayers to be considerate
in this regard and make the prayer short because within the congregation
there may be those who are sick, children, weak, or needy.1 The widespread presence of ethics in acts of worship, in one’s dealings with others,
and in everything else points to the centrality of this virtue in Islam.
One thing that points to the centrality of God-consciousness is that
every prophet commissioned by God told his people to worship God and
to have God-consciousness. The centrality here is clear. If we examine the
matter from a practical point of view, God-consciousness is the only ethical value that is present with every person in every moment, in private and
in public. The Prophet (PBUH) said, “Have God-consciousness wherever
you are.”2 There are things a person does that nobody will ever find out
about and nobody will be able to hold one accountable for. Nevertheless,
a person has an internal accountability to himself that is present with him
wherever he goes. Thus, when we come to the test of practicality of ethics,
we can identify the ethical value of God-consciousness as a central and
pivotal value. Similarly, we say that a doctor should be gentle and humble,
but if both of these are included in the value of mercy, then [it suffices to
say] mercy is the fundamental ethical value and the central moral. This is
why we call for the doctor to exhibit the set of fundamental ethics.
The search for the set of fundamental ethics happens either by pursuing Sharia and looking at its texts that branch off into various legal
domains, or by pursuing practicality. The broader we find an ethical value
and the more prevalent we find it in a person’s life regardless of the texts,
the more evidence we have that this is a central ethical value. This is what
was done by those who examined many ethical values and derived from
them the four principles.
Mohammed Ghaly
To summarize what Sheikh Raissouni said, there are two ways or methods of identifying the set of fundamental ethics. The first is by examining
1
Narrated by Bukhari in Al-Adhan (no. 703) and Muslim in Al-Salah (no. 467) on the
authority of Abu Hurayrah.
2
Narrated by Ahmad in Al-Musnad (no. 21354) on the authority of Abu Thar.
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Script of Oral Discussions (Day 1, Session 1) 303
the texts and sources to determine how central a certain ethical value is
therein and how much it has been mentioned. It is worth noting whether
a particular ethical value was present in the legislations of prophets
before the Prophet Muhammad (PBUH), as its presence would indicate
that it is not exclusive to a specific era or a particular religious law but
rather that it has existed throughout human history. The second way or
method of identifying the set of fundamental ethics is to note the current
reality, meaning a person’s need of a particular ethical value at a particular time in a particular situation. The repeated need for an ethical value in
this way leads to the conclusion that it should be counted among the
fundamental ethics.
Tariq Ramadan
I have some questions. Firstly, when we talk about ethics and the set of
fundamental ethics, are we talking about principles (mabādi’), fundamentals (usūl), or higher objectives (maqāsid)? Even the word principles in
English means both mabādi’ and usūl in Arabic, so what is the correct
understanding of ethics? Does it involve the higher objectives of Sharia or
does it involve principles, and is there a difference between the two?
Secondly, in the first part of your paper you talk about ethics in general then you talk about ethics and medicine. Is there a difference between
ethics in medicine and the ethics of the physician?
My last question is about God-consciousness. Is God-consciousness
universal, such as when a doctor stays behind at the end of his shift for the
sake of God or out of God-consciousness? There are many physicians
who do not recognize God and are far from religion, so can we say that
God-consciousness is indeed universal?
Ahmed Raissouni
Regarding terminology, the word mabādi’ (principles) is a new term that
does not exist in our Islamic heritage except to mean “the beginnings of”
a science or discipline or “the introductions to” a science or discipline.
Thus, I do not usually use the word mabādi’ but rather use the words usūl
(fundamentals), akhlāq (ethics), and fadā’il (virtues), so these are the
words about which I will answer.
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Firstly, all ethics are higher objectives. Messengers were sent for the
purpose of purification of the soul (tazkiyah). This means they were sent
in order for ethics to be present, strong, and effective in the life of the
people. In other words, the purpose was for ethics to be practiced and
embodied by the people. Today people use the term “ethicizing” (takhlīq):
the ethicizing of public life, of politics, of economics, etc. Ethics or ethicizing is a higher objective (maqsid). It is a higher objective of religious
codes of law to transform the human into an ethical being who exhibits
judicious, ethical behavior. In this way, ethics are indeed higher objectives. This is affirmed by the words of the Prophet Muhammad (PBUH)
in his famous narration, “I was only sent to perfect noble character
(makārim al-akhlāq),”3 where “to” here means “in order to,” and thus perfecting noble character or perfecting ethics is clearly an objective.
Ethics are also virtues, albeit the Arabic word akhlāq (ethics) of
course includes both virtuous ethics and reprehensible ethics. When we
say this word we technically mean both kinds, but most of the time we
mean to speak about the virtuous side, which is the more dominant side.
One person’s ethics can include bad morals such as being harsh towards
others while another person’s ethics can include good morals such as
being merciful. Religious codes of law and scholars of ethics often
introduce the positive side first because it automatically negates the
negative side.
Ethical values are also starting points; they are virtues from which a
person springboards, and they serve to guide a person’s behavior and
elevate his actions. Ethics are also fundamentals (usūl) because from
ethics we can derive legislation and [decisions about] behavior. What
counts as a “fundamental” (asl, singular of usūl) is that which gets built
upon or from which something else branches off. The name of this
center is the research Center for Islamic Legislation and Ethics. Ethics
are the fundamentals for Islamic legislation. Yes, the fundamentals for
Islamic legislation are indeed the Qur’an and Prophetic tradition, but
ethics are fundamentals for it also. This is a point that scholars of
3
Narrated by Al-Bazar in his Musnad (15/364) and by Al-Bayhaqi in Al-Kubra (10/191,
no. 21301).
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Script of Oral Discussions (Day 1, Session 1) 305
Islamic legal theory have not paid much attention to, but this center can
renew consideration for ethics in the discipline of legislation. To be
more accurate, ethics is a source for legislation if one cannot find a legal
or legislative text.
With regards to God-consciousness (taqwá), its Islamic meaning is
what we consider to be the most complete and comprehensive. However,
regardless of the presence or lack of religion, God-consciousness is comparable to the human conscience. A person who has a conscience that is
alive and well will hold himself accountable by it and will be guided by
it. He does not need an external authority to watch him or punish him;
rather, he monitors himself. This is a type of taqwá. However, there is a
problem. When a person monitors his own self, after a while his whims
and desires may get in the way and affect his actions, while he still thinks
or claims his actions are compliant with the principles [he aspires to].
With religion, it is more objective than his desires or personal inclinations.
Furthermore, when a person’s taqwá is based on faith and religion,
God Almighty is never absent and never leaves the person. The person’s
awareness and fear of God in the presence of people is like his awareness
and fear of God in their absence. So, he will act according to this awareness. Whoever does not have this awareness and instead acts according to
his own self may go astray, especially in difficult situations. A person
without taqwá based on faith and religion is susceptible to changing and
switching states, so he may exhibit conscientiousness at a certain time but
not at another. We all know this very well. When a doctor or politician
deals with much wealth and is exposed to corruption, he may change and
end up participating in it.
A person with a conscience based on faith — while we do not say he
is free from the possibility of changing — is perhaps more immune and
protected because of the internal monitor that he maintains. To conclude,
conscience is at its best when a person maintains a personal, internal
monitor that he does not separate from, and this is actualized if the conscience was based on faith and religion. If this is actualized without
faith, the success differs according to the differences of people. We
believe that conscience is most complete and lasting when it springs
from faith and creed.
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Jasser Auda
I have a question about considering higher objectives (maqāsid) and
ethics to be fundamentals (usūl). If we do consider them as fundamentals,
then practical rulings should be based on them since this is the definition
of fundamentals. Yet how can practical actions be based on fundamentals
of higher objectives and ethics? You touched on this point when you said
that if there is no basis in the text, then rulings should be based on the
higher objectives and ethics. However, is the text in and of itself connected with these ethics? In other words, can we consider the higher
objectives and the ethics — meaning the fundamentals — principles in the
modern philosophical meaning of being that which, alone, practical rulings are built upon? And what are the conditions if so?
Ahmed Raissouni
When we examine and study the [religious] texts, we are led to conclude
that they are all based on ethics. Exhibiting honesty and trustworthiness,
maintaining gentleness, and taking into account the interests of people are
all examples of higher objectives and ethics. For example, we learn from
the Prophetic example that it is not acceptable for a person to surprise
another with alarming news, even if it is true. So when someone has bad
news to break to another, he should circumvent its harshness and try to put
it as gently as possible. If we take the example of the penal law (‘uqūbāt),
which is seemingly far from our discussion, it is also built on ethics. The
punishments for, for example, committing fornication, murder, or theft
serve as deterrents to committing atrocious unethical acts. Similarly, for
contracts and sales, we are required to be faithful and to honor the deals
or contracts into which we enter: “O you who have believed, fulfill [all]
contracts…” (Qur’an 5:1). Honoring contracts is a general fundamental
(asl ‘ām) and is first and foremost a part of ethics.
Similar to other scholars, the prominent scholar and author of Adwā’
al-bayān, Muhammad Al-Amin Al-Shinqiti, in his commentary on the
verse, “And indeed, you [O Muhammad (PBUH)] are of a great moral
character” (Qur’an 68:4), inquired, what was the Prophet Muhammad
(PBUH) upon such that he would be described as being of great moral
character? He was upon Islam. Therefore, Islam in its entirety is ethics
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Script of Oral Discussions (Day 1, Session 1) 307
and the Prophetic Tradition in its entirety is ethics. So interpreters of the
Qur’an explained the verse, “And indeed, you are of a great moral character” as meaning he was upon Islam. Furthermore, the Prophet’s wife,
‘A’ishah — may God be pleased with her — said that the Prophet
Muhammad’s (PBUH) ethics were the Qur’an. Therefore, the whole
Qur’an is ethics; Islam in its entirety is ethics; ethics is what the Prophet
Muhammad (PBUH) was upon; and it is to this end that he was sent.
Therefore, when we follow the texts, we realize that they are based on
ethics at both particular and general levels.
If we adopt the above understanding and acknowledge that the
scholars — such as Al-Shatibi, Ibn Al-Arabi, and Al-Ghazali — deduced
the “mother” of fundamentals (ummahāt al-usūl), then these fundamentals
become governing upon human behavior, whether under the direction of
a text or under the direction of ethics. Furthermore, it is important to note
that a person’s method of applying a text can vary. He can apply the text
in a dry, legal way or in an ethical way that emphasizes mercy and compassion towards others. The latter method should be followed. We have an
example in the famous Prophetic narration, “…Verily God has enjoined
goodness to everything; so when you kill, kill in a good way and when
you slaughter, slaughter in a good way. So every one of you should
sharpen his knife, and let the slaughtered animal die comfortably.”4 So a
person can kill in a way compliant with Sharia, or he can kill in an inhumane and atrocious way. Applying the texts with ethical considerations
is one option, and applying the texts without ethical considerations is
another one. When there is a lack of textual evidence, the matter is decided
based upon (i) the ethics since the ethics are themselves higher objectives
and (ii) the rest of the higher objectives of Sharia.
Ethical values in Islam are not confined to chapters and books dedicated specifically to them; rather, ethical values pervade all chapters, rulings, and Sharia-based obligations, including creed, ritual acts of worship,
habits, contracts, dealings with others, criminal law, and politics. All of
these domains have the stamp of ethics, are built on ethics, and are ruled
by ethics.
4
Narrated by Muslim (no. 1955) on the authority of Shadid bin Aws. Editor’s note: The
speaker quoted a shorter part of the narration (until “slaughter in a good way”); of the
remaining part of the narration has been included here for elaborating the full context.
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Jasser Auda
If there is a text that points to a particular ethical value, does this ethical
value control how we interpret the text? Let us take as an example a text
that points to the ethical value of mercy. Is it the case that mercy is the
essential point of the text and that the particular manifestation of mercy
present in the text is just a means that can change?
Ahmed Raissouni
I think this necessitates a more detailed discussion in the science of
Muslim legal theory (usūl); it has to do with the relationship between connotations (dalālāt) and effective causes (‘ilal). In this regard we can refer
to what Al-Shatibi says and most Muslim legal theorists also agree with:
we should respect what the text says outwardly and the text’s particular
wording. However, in parallel, we should pay attention to the meanings
and the higher objectives of the text. As Al-Shatibi said, this is a difficult
task but is the more rightly guided way. That is, how does one maintain a
balance between respecting the text and its wording and taking into
consideration the text’s meaning alongside the more general meanings
present in other texts and in our human natural disposition (fitrah)? To this
last point, Ibn ‘Ashur held the opinion that our human natural disposition
itself can be taken as a reference. As a matter of principle we have to take
this balance into consideration.
The natural question here is: What happens if when the wording of
the text is applied, it seemingly contradicts the [relevant] higher objective in some cases? Here, we can limit the text’s applicability to a particular situation or to special circumstances such that the application of
the text would in fact lead to the avoidance of evil or hardship on people.
This is what ‘Umar bin Al-Khattab did in the Year of Ramadah, and
Sheikh Bin Bayyah alluded to this by saying that there are some rulings
we can place on a temporarily extended leave (in other words, we can
choose to not apply them) because the conditions, challenges, and obstacles of the current situation necessitate that we operationalize another
text for this situation.
We all know the famous fatwa of Ibn ‘Abbas. While amongst his students, Ibn ‘Abbas was asked by a man, “Can someone who intentionally
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Script of Oral Discussions (Day 1, Session 1) 309
kills a Muslim repent?”5 Ibn ‘Abbas looked at the questioner with scrutiny
and replied with a no, stating that a person who commits this act would be
condemned to Hell. After the questioner left, the students of Ibn ‘Abbas
then questioned their teacher, saying, “Didn’t you used to give the fatwa
that the repentance of someone who kills a Muslim intentionally can be
accepted?” Ibn ‘Abbas said, “I saw in this man’s eyes evil, as if he desired
to kill somebody. It seemed he was waiting for a fatwa from me so that he
could go kill someone and then repent.” Ibn ‘Abbas found that his original
fatwa would now, in this situation, lead to an act of killing. This is why
Ibn ‘Abbas told the questioner that such a person would be condemned
to Hell.
Of course, the words of Ibn ‘Abbas here are valid because the
Qur’anic verse states, “But whoever kills a believer intentionally — his
recompense is Hell, wherein he will abide eternally, and God has become
angry with him and has cursed him and has prepared for him a great punishment” (Qur’an 4:93). But of course, due to the mercy of God and the
intercession provided by belief in Him, there is the possibility of God
accepting repentance for this act [as indicated by other Qur’anic texts]. In
this specific case, with this particular questioner, it is as if Ibn ‘Abbas
suspended his original fatwa — or put a hold on the apparent meaning of
the text — and issued a different ruling based on the conditions. This all
goes back to the scholars, legal jurists, and trustees of Sharia.
Mohammed Ghaly
I had a comment about the issue of taqwá. First, I have noticed that taqwá
is normally translated as “piety” or “fear of God.” However, through the
in-depth academic studies that have been carried out, we know the Arabic
word encompasses more than piety and fear of God. In my opinion, the
best translation that has been put forth so far is “God-consciousness.” So
if we consider taqwá to mean God-consciousness but we remove the
word “God” and replace it with the word “self,” that could make it universal since we would end up with the word “self-consciousness” or
simply “conscience.” This is a term that is perhaps more familiar in
Western circles of bioethics and medical ethics.
5
Narrated by Ibn Abi Shaybah in Al-musannaf, Book of Al-diyyāt (5/435).
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Furthermore, in the West, the dependence on or incorporation of
one’s religion — whether it is the doctor’s or the patient’s — is considered potentially problematic from an ethical point of view. The doctor is
expected to be neutral, meaning the issue of religion should not have an
effect on his work. Of course, on the other hand, this does not imply the
lack of accountability. Dr. Bredenoord, do you have anything to say
about this?
Annelien Bredenoord
What strikes me is the similarity between what we call the concept of
autonomy and the concept of taqwá. I would like to ask some questions
about that. First, I would like to ask Sheikh Raissouni about what he
called principles. I would like to know whether there is a hierarchy for
these principles. Is there one principle more important than the other principles? In our principles approach, one major discussion is about whether
there is a hierarchy. Is one principle more important than the others?
My second question is about taqwá. What is striking about the principle of autonomy, which is defined as self-rule, is that it is also defined
as consciousness. It is about having discipline to achieve one’s aims. It is
about judging for yourself instead of being judged by authorities. It
is about following your own moral rule. If you interpret it in this way, it
has many similarities with the concept of taqwá. So if we define autonomy as some kind of consciousness, I would be interested to hear what
other similarities it has with taqwá.
Ali Al-Qaradaghi
I would like to make a few comments about what Sheikh Raissouni has
said. If we follow the methodology of the Muslim legal theorists
(usūlīyūn) in the issue of al-sabr wa-al-taqsīm (examining all possible
rationales and then selecting the appropriate one), especially in the scope
of Islam and other religions, then we would find all these things refer back
to God-consciousness. However, in my opinion, God-consciousness has a
religious connotation because it is related to the idea of fear of God since
it is the fear of God that makes you feel that you are being observed by
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Script of Oral Discussions (Day 1, Session 1)
311
Him and thus should be conscious of Him, as Dr. Chamsi-Pasha has
pointed out previously. If we link God-consciousness with this meaning
then we will find, as Dr. Bredenoord has suggested, that some ramifications of God-consciousness are indeed present in human conscience and
in autonomy. However, God-consciousness encompasses much more.
Therefore, if we chose to restrict the scope of biomedical ethics to Godconsciousness, I think this would be valid from the [theoretical] perspective of fundamentals (usūl). However, from a practical perspective, we
would need to specify fundamentals and principles besides Godconsciousness. We do not want to expand the number of ethical values to
reach the hundreds, and we also do not want to limit them to just one
ethical value that would need further detailing and elaboration.
The second point is about considering ethics as fundamentals on
which legislation may be made. Someone touched upon the situation
where there is no text [on which to base the legislation of a certain issue].
In my opinion, the ethical values and the higher objectives should be used
as part of the measuring criteria one employs when issuing a fatwa and
engaging in independent legal reasoning (ijtihād).
Muhammad Ali Al-Bar
There are a few issues to consider as we further our understanding of the
concept of ethics in general. The first is about human natural disposition
(fitrah), which is mentioned in both the Qur’an and the Prophetic
Tradition. It is a basic and fundamental aspect of a person. Everybody
knows that lying is wrong and telling the truth is virtuous. Everybody
knows that killing an innocent person is a crime and that saving an innocent soul is morally commendable. God has made these ethics innately
intuitive to us. Whether or not a person is conditioned in such a way that
encourages or discourages him from these ethics is a different issue.
The second issue is reason or the intellect. God in the Qur’an
addresses the reader’s intellect and encourages him to use reason. He says,
“…Then will you not reason?” (Qur’an 2:44) and, “…‘Then will you not
give thought?’” (Qur’an 6:50). The intellect is a scale by which a person
knows truth as truth and falsehood as falsehood. For example, how do I
know that a particular religion is true or false? The basis for answering
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such a question is the ability of sound thought and reasoning that God has
bestowed upon us as human beings. Again, this is irrespective of whether
that reasoning is tampered with at some point in a person’s life.
The third issue is religion. As narrated in the Prophetic tradition, God
sent 124,000 prophets and many messengers. They all came with one
message, not differing except in the details [of legislation]. It has been one
message from the time of Adam to that of the Prophet Muhammad (peace
and blessings be upon them).
Islam and all religions have incorporated these three elements —
human natural disposition (fitrah), reason or intellect, and the divine
message — into their teachings. Indeed, these three elements are practiced by all of humankind, in both primitive and advanced civilizations,
both ancient and modern ones. Over time, these positive ethical elements
may be suppressed by the negative effects of the environment and other
things. If you remove the negative effects, then human natural disposition (fitrah), reason or intellect, and the one true message become apparent. The three elements are present among all groups of people across
humanity.
There is no doubt that the details may differ. Honesty, as Dr. ChamsiPasha previously pointed out, is a foundational principle at all times, and
lying is considered a crime ethically speaking. So I must inform a patient
of his illness, and if I do not inform him then I am a liar. People across
civilizations do not differ on this; instead, they may differ in the method
used or in the details.
A final point I would like to address is the relationship between ethics
and interests (masālih). In Islam, some interests have to be restricted.
Utilitarianism on the other hand may consider selling cigarettes or alcohol
an interest worth pursuing if it benefits a group of people. There is disagreement between our philosophies in this matter as well as in the matter
of autonomy, which will be discussed later.
Abdul Sattar Abu Ghuddah
Sheikh Raissouni started by saying that all of religion goes back to ethics.
In my opinion, religion is ‘aqīdah (creed), Sharia, and ethics. So when we
restrict religion to ethics alone, we run the risk of neglecting revelation
and the texts; of course, Sheikh Raissouni did not mean this. He mentioned
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Script of Oral Discussions (Day 1, Session 1) 313
a verse in which we are informed that God sent Prophet Muhammad
(PBUH) to purify the people (yuzakkīhim) [of inclinations towards wrongdoing], and if we continue the verse, we find that it also says, “…and
purifying them (yuzakkīhim) and teaching them the Book and wisdom…”
(Qur’an 3:164). So we need both tazkiyah (purification), which represents
ethics, and abiding by legislation in the Qur’an and the Prophetic tradition. Some have interpreted the word “wisdom” in the verse to refer to the
Prophetic tradition.
I would like to refer here to Imam Al-Shatibi and his student
Muhammad Al-Sheikh. They said the objective of legislation and religion
is for a (morally responsible) person to exit the state of submission to his
desires so that he may enter into a state of submission to God voluntarily,
like he is in a state of submission to God necessarily.6 Therefore, it is
necessary to abide by the obligations ordained by God, some of which
have purposes that are clear to us while others do not. The important thing
is obeying His commands.
As for taqwá (God-consciousness), scholars of Sharia have defined it
as doing the actions that God has commanded and avoiding the actions
that God has forbidden. From where do we derive these commandments
and forbidden acts? We derive them from religion. That is why we need
to focus on the fact that Sharia is a reference for ethics and not vice versa.
Likewise, creed (‘aqīdah) is a reference for ethics. For example, the idea
of succession (istikhlāf ) on earth is a matter of creed, and it prompts a
person to realize this succession through abiding by the rulings of Sharia.
For a believer, God-consciousness comes about in this way.
For a non-believer, how does God-consciousness come about? As you
know, there are traders who perform their work properly, do not cheat
others, and are committed to the morals of their trade while their goal is
materialistic: they want to gain customers and do not want customers to
lose trust in their business. This is also considered taqwá: such a person
fears something that is, in his opinion, high. This applies in medicine as
well. The physician who wants to preserve his reputation in order to have
more also exhibits a kind of taqwá. This type of taqwá is in isolation from
the religious element that involves the concept of being observed by God
6
Al-Shatibi, Al-Muwāfaqāt (2/282).
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and being held accountable to Him. If such a doctor had the opportunity,
without anyone noticing, to do something wrong that benefited him, he
may take that opportunity because he has no concept of being observed by
or held accountable to God.
Regarding fundamentals (usūl), we cannot say that the fundamentals
are based on ethics. Rather, ethics are based on the fundamentals. The
fundamentals permit us to follow the “absolute benefit” (al-maslahah
al-mursalah), which is defined as something that the religious texts are
silent about but that is in itself beneficial. If something is established as
an “absolute benefit,” then it is considered to be among the general [ethical]
principles. Ethics in general can be derived from interests (masālih) that
have benefits for people. I hope we do not focus on one side at the expense
of the other.
Ahmed Raissouni
Regarding Dr. Bredenoord’s question about whether principles and ethics
exist in a hierarchy, I would say in principle, the answer is yes. Islam in
its entirety, as it has been detailed by scholars, is built upon the concept of
hierarchy. This concept exists in the verse, “Have you not considered how
God presents an example, [making] a good word like a good tree, whose
root is firmly fixed and its branches [high] in the sky? It produces its fruit
all the time, by permission of its Lord…” (Qur’an 14:24–25). In Islam,
everything is built starting from a word and grows from there to become
bigger and bigger.
Turning now to the higher objectives of Sharia, it is well known how
they were organized and how the five necessities (darūrīyāt) were categorized and how the rest followed. The same thing applies to ethics. There
is a prioritization such that some ethics are ordered above others and some
ethics branch off of others, etc. In principle, this usually is taken by
default. However, personally, I have never attempted to set this kind of
hierarchy apart from what pertains to the topic of God-consciousness.
I quoted in my chapter and am convinced by the words of Muhammad
Abdullah Draz. God-consciousness is the most comprehensive ethical
value, and it is the ultimate source and fountainhead of ethics.
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Script of Oral Discussions (Day 1, Session 1) 315
We heard many perspectives and comments on the religious and
non-religious interpretations of God-consciousness. Sheikh Abu Ghuddah
suggested it is striving to obey God’s commands and avoid God’s prohibitions. Perhaps this is not God-consciousness but rather the fruit of Godconsciousness. As for God-consciousness (taqwá) itself, one companion
of the Prophet (PBUH), ‘Umar bin Al-Khattab, asked another, Obayy bin
Ka‘b, “What is taqwá?” He replied, “Have you walked along a thorny
path before?” He said, “Yes.” He asked him, “How did you do so?” He
replied that he would walk carefully, vigilant of where he stepped and
turning this way and that [so the thorns did not hurt him]. He answered,
“This is taqwá.” In other words, God-consciousness means that a person
must always be vigilant of where he is going to set his foot and hold
himself accountable before being held accountable by God. These are the
traits of a person who practices God-consciousness. However, as I said
before, God-consciousness is achieved sustainably and completely only
through revealed religion.
Regarding a physician’s practice of religion or lack thereof and
regarding the religiosity of ethics, I think the fundamental fountainhead of
ethics is religion, whether that of Muslims, Jews, Christians, Buddhists, or
others. Even those who reject religion use religious ethics but strip them
of their religious source or background. As the saying goes, they took the
fruit and ignored the tree. Yet they must know that the fruit is bound to be
eaten or to rot and the tree is more lasting and thus is what we have to go
back to. It is true there are those who have adopted ethics without adopting religion and those ethics are valid; my point is that the source of those
ethics is religion. I believe that without religion these ethics will come to
an end or will be faced by many obstacles such as obstacles of trade or
other interests. Each doctor of course does as he wishes, but from a purely
scholarly or academic perspective, ethics without religion will eventually
be distorted and come to an end.
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Islamic Perspectives on the Principles of Biomedical Ethics
Formulating Ethical Principles
in Light of the Higher Objectives
of Sharia and Their Criteria
Ali Al-Qaradaghi
Abstract: This chapter is divided into three main sections. The first section
is an attempt to explain how the higher objectives of Sharia can be utilized
to draft an Islamic version of biomedical ethics. Besides the well-known six
higher objectives (viz., protecting religion, life, intellect, wealth, offspring,
and honor), the author adds two others, namely preserving the integrity
of the legitimate state and the integrity of society. The second section is
dedicated to a number of legal maxims and rules by which the objectivesbased approach for the principles of biomedical ethics can be specified and
applied with a considerable degree of precision. In this context, reference
is made to legal maxims like, “There should be neither harming nor
reciprocating harm,” and “Certainty cannot be overruled by doubt.” The
author also makes reference to the so-called “jurisprudence of balances (fiqh
al-muwāzanāt)” by which the possible clash between benefits and harms in
specific cases can be avoided or resolved. The third section provides a list
of virtues and etiquettes to which physicians should adhere, most of which
can be summed up into two, namely professionalism (ikhtisās) and sincere
devotion (ikhlās). The percept of confidentiality and the duty to keep all
information between physician and patient private are also underscored.
317
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In the name of God, the Most Gracious, the Most Merciful.
Praise be to God, The Lord of the worlds, and peace and blessings be
upon our beloved example Prophet Muhammad, who was sent as a
mercy to the worlds, upon his brothers the prophets and messengers, his
virtuous household, his blessed companions, and those who follow them
in excellence until the Last Day.
1. A Well-constructed Formulation of Effective Ethics
in Light of Tremendous Medical Advancements
The world we live in today constantly witnesses immense developments
and discoveries in areas of science, technology, communication, and travel.
The field of medicine is no exception: it has undergone tremendous revolutions in specialties such as biology, optics, and genetic engineering. The
ground-breaking discovery of the genetic code in May 2001 has led to
incredible progress in biomedical knowledge and has been accompanied
by impressive research and discoveries in the fields of genetics, embryo
cloning, in vitro fertilization, artificial insemination, human genome projects, gene therapy, organ transplants, stem cells, and numerous others.
In light of this considerable progress and these remarkable discoveries, it becomes incumbent upon us to pay due attention to the nurturing
and ingraining of ethics in the hearts of those practicing within these
fields. No effort should be spared to ensure a full commitment to ethical
principles, as the separation between ethics and scientific advancement
often leads to consequences that endanger humanity and potentially result
in unknown harm in the long term.
The separation of ethics and law has existed since the development of
Roman legislation. This was followed, throughout the last four centuries,
by the European revolutions against despotism and the Church. As a
result, religion was separated from the state, and even from life itself,
leading to a spiritual vacuum accompanied by dangerous consequences.
In time, several wise and rational individuals highlighted the enormity of
this issue, especially in light of the rapid progress achieved in science and
technology. Consequently, several positive efforts took place, and the field
of ethics received the undivided attention of philosophers, scholars, and
researchers. Ethical issues, both general and medical, dominated scientific
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Formulating Ethical Principles 319
journals in order to emphasize the criticality of identifying the advantages
and disadvantages of biotechnology and to ensure the application of ethical principles so as to minimize harm or completely avoid it wherever
possible.1 Moreover, specialized academic centers with international
committees and associations were established with the purpose of regulating ethical issues and establishing authoritative sources of reference for
scholars and researchers. The most prominent amongst these committees
are the International Bioethics Committee (IBC), the International Union
of Biological Sciences (IUBS), and the Eubios Ethics Institute.2
Arising from their recognition of the importance of ethics, European
and American scholars have exerted noteworthy efforts in addressing this
issue through several ethical theories, including:
(i) Utility theory, which is based on promoting benefit. It aims to
achieve maximum advantage with the least disadvantage possible.
However, the weakness of this theory lies in the fact that it accepts
ethical violations as long as there is a benefit to be gained. This
theory emerges from the well-known philosophy of utilitarianism,
which has been adopted by many people.
(ii) Immanuel Kant’s categorical imperative and deontology theories.
According to Kant, the justification for moral action should be based
on duty and commitment, not merely arising from emotions and
conscience. The problematic issue in this theory is how to ensure
compliance with ethics.
(iii) The rights-based theory. This theory is based on an individual’s right to
life, property, and freedom. Contention in this theory arises when individual rights occasionally contradict with the rights of the larger group.
(iv) Communitarianism, which is based on promoting general welfare
and community-based objectives and preserving community norms.
The problem with this theory lies in the fact that it often neglects
individuals’ rights.
1
Talal Al-Zoabi (2008). “Al-mabādi’ al-akhlaqīyah allatī yastanid ilayhā talabat kulliyat
al-tibb fi al-Jāmi‘ah al-Urdunīyah fi isdār hukmihim ‘alā al-qadāya al-akhlāqīyah wa mā
madā ta’thīrihā bi-kul min al-jins wal-mustawā al-dirāsī wa mustawā fahmihim li tabī‘at
al‘ilm”. Al-Najah University Journal for Researches (Human Sciences) 22(4): 1191–1215.
2
Ibid.
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(v) The theory revolving around familial relationships and the
physician–patient relationship. However, this theory does not
address ethical problems in general.
(vi) The theory of casuistry, where decisions are made based on the specific conditions surrounding each case. This can be problematic
when there are several contradictory decisions and when personal
bias is involved.3
(vii) The Four Principles of Biomedical Ethics developed by Beauchamp
and Childress, which is the focus of this chapter. In my opinion, this
last theory is the most comprehensive. However, it is not free of
remarks made by myself and others.
2. Ethics in Islam: An Overarching Purpose, Not a Means
As one explores the Sharia texts, ranging from those related to creed and
the revelation of divine books, sending prophets, worship, and rituals to
those concerned with interpersonal relationships, economics, legal punishments, family affairs, politics, and jihād, it becomes evident that the
primary focus is on attaining virtue, reinforcing noble values, and maintaining excellent behavior so as to enable society to lead a happy life.
Ethics do not form a separate branch of Islam but rather are a fundamental
objective that pervades all elements of life. Ethics are essential to a person’s survival just as a soul is to human life, blood is to a human body, or
water is to the life of plants. In this sense, the Noble Qur’an summarizes
the objectives of sending the Prophet Muhammad (PBUH) by referring to
the concept of mercy — namely a mercy for all humans, animals, and
inanimate creatures — and he is considered the epitome of ethics and
values. God says, “And We have not sent you, [O Muhammad], except as
a mercy to the worlds” (Qur’an 21:107). The Prophet (PBUH) similarly
summarizes the objectives of his message as the perfection and application of noble behavior, stating, “I was only sent to perfect noble character
(makārim al-akhlāq).”4 Furthermore, God the Almighty, in describing the
3
Omar Hasan Kasule (n.d.). Al-akhlāqīyāt al-tibbīyah min al-maqāsid al-shar‘īyah.
Available online via http://forum.makkawi.com/showthread.php?t=29311 (retrieved 11
November 2013).
4
Narrated by Al-Bazzar in his Musnad.
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Formulating Ethical Principles 321
Prophet (PBUH), chose to highlight the best of his attributes, proclaiming,
“And indeed, you are of a great moral character” (Qur’an 68:4).
One of the most important objectives of believing in God and the Last
Day is for the believer to attain a level of God-consciousness enabling him
to abstain from immoral behavior. The Qur’an includes a multitude of
examples in this regard that would be difficult to sufficiently elaborate on
in this chapter.
3. The Foundations of Ethics and their Status in Islam
In Islam, the concept of ethics encompasses the whole set of values and
ideals that had been previously established by all divine religions as well
as those values towards which the natural disposition (fitrah) of human
beings has been inclined throughout history. As such, Islamic ethics are
rather expansive, numerous, and diverse, as made evident by their dominance across most Qur’anic verses and Prophetic narrations (hadith).
Throughout these verses and Prophetic narrations, a strong emphasis is
placed on the human individual as the initiator and agent of these ethics.
Islam then guides us to focus on nurturing the foundations that are the
core of a person’s ethical conduct, namely the heart, soul, mind, and spirit.
Prophet Muhammad (PBUH) advises us, “Beware! There is a piece of
flesh in the body that if it becomes good (reformed), the whole body
becomes good but if it gets spoilt the whole body gets spoilt, and that is
the heart.”5 Likewise, God the Almighty stresses the importance of these
internal elements for genuine change and reform and in achieving happiness and progress (and vice versa), stating that, “Indeed, God will not
change the condition of a people until they change what is in themselves…” (Qur’an 13:11). Countless experiences, events, and realities
have reinforced the fact that internal transformation (of the soul and the
heart) can best be attained by connecting them to God the Almighty and
the Last Day. This is because there is no temporal law with the authority
or ability to regulate or monitor a person’s soul and heart. These laws are
only capable of judging external behavior, while internal motivations are
known only to the One Who sees them, namely, God the Almighty.
5
Narrated by Bukhari, Iman, no. 52.
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This is the approach adopted by Islam (and all true, divine religions)
towards a person’s internal reform and development. It is an approach that
has proven successful in the reform of individuals, which in turn leads
to the reform of families, communities, and nations. Based on this, the
foundations of ethics can be traced back to the original concept of Godconsciousness.
4. Delineating Ethics According to their Origins
Islamic ethics and values are abundant. An investigation of the books of
Prophetic traditions will unequivocally reveal hundreds of chapters that
address ethics directly or indirectly.6 One perspective through which
ethics may be delineated involves linking them to the eight higher
objectives (maqāsid) of Sharia as will be demonstrated later in this chapter. A second perspective involves associating them with the following
moralities:
•
•
•
•
A positive relationship between a person and his Lord.
A positive relationship between a person and other people.
A positive relationship between a person and animals.
A positive relationship between a person and the environment.
These ethics, values, virtues, and ideals can also be delineated from a
third perspective, which involves ranking them in terms of strength, outcomes, impacts, and associated punishment. For instance:
(i) Islam categorizes some ethics as obligations and duties whereby their
violation entails legislative action and punitive measures.
(ii) There are other ethics that have been ordained by God, but worldly
punishments were not set for those who violate them.
(iii) Ethics such as altruism are categorized in Islam as virtues and ideals
to which one should aspire.
6
See the books of hadith, especially Sahīh Bukharī, Sahīh Muslim, Al-Sunan al-arba‘ah,
Al-muwaṭṭa’, and Sunan al-Dārimī; where we find hundreds of sections about ethics.
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5. The Theory of Drafting Ethical Principles in Light
of the Higher Objectives of Sharia
As clarified earlier, ethics and morals are not merely peripheral ornaments
of the Muslim character but rather are considered fundamental goals for
all divine religions, which the Qur’an came to complete and perfect.
Those ethics that are paramount were categorized as obligations and
duties, while contemptible behaviors were classified as major sins and
prohibitions. Other behaviors that do not negatively impact others were
categorized either as recommended acts such as altruism, excessive generosity, or excessive courage (given that it is not recklessly excessive), or
as reprehensible acts such as refusing to offer regular assistance given that
no harm comes of it, etc.
Given this comprehensive nature of ethics in Islam, it is best that they
are framed in alignment with the higher objectives of the Sharia, its purposes, philosophy, and types of wisdom. This is the methodology I will
attempt to follow. As is commonly induced, Sharia is aimed towards the
fulfillment of necessities (darūrīyāt), needs (hājīyāt), and luxuries
(tahsīnīyāt) in five or six areas (or perhaps more). This has been reiterated
by scholars ranging from the time of Imam Al-Haramayn, Al-Ghazali,
Al-‘Izz bin ‘Abd Al-Salam, Ibn Taymiyah, Ibn Al-Qayyim, and Al-Shatibi,
up to contemporary scholars such as Ibn ‘Ashur and others.7 The six
objectives of Sharia have been identified as the preservation of religion,
life, intellect, wealth, offspring, and honor. In a previous research project8
of mine I suggested adding two other objectives: the security of the legitimate state and the security of communities and societies. The combination
of these eight objectives encompasses the preservation and promotion of
the individual’s objectives, as well as those of communities, societies, and
nations.
7
For more information, see Al-Shatibi (1994). Congruencies in the Fundamentals of the
Revealed Law (Al-muwāfaqāt fī uṣūl al-sharī‘ah), Muhammad Abdullah Draz (ed.). Beirut:
Dar Al-Ma‘rifah; Ibn ‘Ashur (2004). Maqāsid al-sharī‘ah al-Islāmīyah, Qatar: Ministry of
Endowments and Islamic Affairs; Ahmed Raissouni (1995). Nazarīyat al-maqāsid ‘ind
Al-Shatibi. Herndon, Virginia: International Institute of Islamic Thought; and Yusuf
Al-Qaradawi (2006). Dirāsah fī fiqh maqāsid al-sharī‘ah. Cairo: Dar al-Shuruq.
8
See Ali Al-Qaradaghi (2010). Haqībat tālib al-‘ilm al-iqtisādīyah. Beirut: Dar Al-Basha’ir
Al-Islamiyah, vol. 1, 188.
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According to the perspective put forth by this theory of objectives,
each objective is consists of three levels — necessities (darūrīyāt), needs
(hājīyāt), and luxuries (tahsīnīyāt) — and also incorporates two elements. The first is an element of actualization (wujūd) or positive obligation, i.e. the promotion and development of interests and benefits,
through the provision of necessities, followed by needs and then by
luxuries. The second is an element of elimination (‘adam) or negative
obligation, i.e. eliminating or preventing harm, malevolence, and corruption. These objectives and rules are central to both the physician and to
the morally accountable patient (or his or her guardians if the patient is a
minor). This theory can be applied to ethics or principles of biomedical
ethics as follows:
5.1. The Preservation of the Higher Objective of “Religion”
The preservation of religion in this context refers to two issues. The first
issue is concerned with the preservation of Islam’s principles and rulings, as Islam is the last of all divine religions. Since our discussion is
focused on medical ethics, all divinely established ethics, values, ideals,
and virtues are verily categorized under medical preservation and care
according to their respective levels of strength, obligation, and so forth.
Medical preservation and care likewise includes all common ethical
principles and virtues such as abstaining from murder and theft; preventing evil and harm; honoring promises and contracts; saving those at risk;
exonerating the innocent; and practicing honesty, integrity, sincerity,
altruism, truthfulness, kindness, generosity, and empathy, in addition to
all other morals as identified in the Qur’an and Prophetic tradition. The
general principles of Islam are similarly included, such as justice, equality, seeking counsel, and respecting human rights. It is imperative that
the concept of preservation and care in medicine incorporates both elements of positive and negative obligations, whereby people’s interests
and benefits are promoted and any harm or corruption is prevented from
coming to them.
The second issue is the preservation of the patient’s religion and
avoiding any practices that may undermine it. Therefore, the physician
should not attempt any experiment or prescribe a cure that conflicts with
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Formulating Ethical Principles 325
the patient’s religious beliefs except in cases of extreme necessity or
unequivocal need. In such cases, a physician may only use a proscribed
treatment in the absence of alternative permissible treatments. This is in
accordance with the Islamic principles, which read, “Necessity overrides
religious prohibitions,” and, “Dire need for medical treatment can acquire
the status of necessity.”9
A physician’s ethical conduct entails that he respects the patient’s
beliefs and does not exploit a patient’s vulnerability to impose other
beliefs. For example, this is often practiced by Christian missionaries who
exploit the dangerous triad of disease, ignorance, and poverty to proselytize religion. On the other hand, the patient is also responsible for maintaining his or her religion. The patient must adhere to the legal rulings of
Sharia when seeking treatment, especially given that undergoing treatment may often be obligatory if rejecting it would lead to definite harm.
Similarly, treatment may be prohibited if it utilizes forbidden means,
except in cases of necessity.
It is important to note that preserving this higher objective also
entails abstinence from everything that is deemed religiously forbidden
and prohibited by Sharia in regards to a person’s life or physical body
(both externally and internally). This includes allowing a fetus to be
killed, donating vital organs, altering natural appearance, human cloning,
abortion, and all similar practices that God has forbidden. Likewise,
these are all considered unethical actions if practiced by a physician and
are simultaneously categorized under the preservation of life as is
explained below.
5.2. The Preservation of the Higher Objective of “Life”10
This higher objective refers to a person’s physical body, including all
internal and external organs. Ethical principles in this regard entail that the
physician and the patient prevent any malevolence and harm from coming
9
See Ali Al-Qaradaghi, Jurisprudence of Contemporary Medical Issues (Fiqh al-qadāyā
al-tibbīyah al-mu‘āsirah). Beirut: Dar Al-Basha’ir Al-Islamiyah: 225.
10
For more details, see entry on nafs in: Al-Asfahani (1991). Sharḥ al-mufradāt li-gharīb
al-Qur’ān, Damascus and Beirut: Dar Al-Qalam & Al-Dar Al-Shamiyah.
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to a person’s life and that they promote a person’s welfare and interests.
Consequently, the use of any medication, treatment, or experiment that
harms one’s body, organs, or internal systems or does not result in benefits
is considered unethical, and both the physician and the patient are forbidden from utilizing it. This is because, in Islam, a person does not own his
or her life, organs, internal systems, or any other part of the body; instead
they all belong to God the Almighty.
The issue of organ donation during one’s life is tied with this Islamic
principle. The primary ruling for this issue is prohibition, unless it has
been categorically proven that donating the organ will not result in any
harm to the donor and that it is in the best interest of the patient. It is
similarly for this reason that the donation of unpaired vital organs like the
heart or liver is absolutely forbidden. Likewise, killing a patient for the
sake of relieving him from an incurable disease (euthanasia) is considered
unethical in Islam and in all divine religions, even if permitted by the
patient, as it is not a right he has. In fact, it is considered a transgression
against one of the rights of God the Almighty. Plastic surgeries that alter
a person’s original attributes also fall into this category, as do issues of
cloning, abortion, and genetic manipulation.
In the case where a patient has passed away, organ donation is considered lawful given that consent has been provided through the patient’s will
or by his or her heirs and that it is in the best interest of the recipient.
Resolutions in regards to these rulings have been issued by the International
Islamic Fiqh Academy (IIFA), the Islamic Fiqh Academy (IFA), and the
European Council for Fatwa and Research (ECFR).11
It is worth mentioning that the term life in this context may also refer
to a person’s soul, which could either be at peace (content, self-assured,
and unwavering) or unsettled due to psychological diseases. Once again,
the preservation of this higher objective may require a balancing of both
positive and negative obligations and refraining from the use of any treatment or medication that may have negative psychological or emotional
effects. In these cases, the physician must attempt to balance between
informing the patient of all necessary details regarding the disease and
11
See Group of Scholars (1990). International Islamic Fiqh Academy Journal (6/3): 1739,
1791, 1975, 2161.
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treatment and withholding any information that may lead to the patient
losing hope or rejecting treatment.
5.3. Ethical Principles Associated with Preserving the Higher
Objective of “the Intellect”
Owing to the utmost significance and role of the intellect (‘aql) in a person’s life, a distinct higher objective is dedicated to it. Linguistically, the
word ‘aql, is defined as the cognition and realization of matters as they
are in reality and the ability to distinguish between them.12 The technical
definition, however, has stimulated extensive philosophical debates.
According to Muslim scholars, it is defined as the instinct through which
God has distinguished man from the rest of creatures. In its absence, there
can be no accountability (taklīf) placed on a person.13 It also refers to the
process of grasping theoretical knowledge. In his definition, Al-Ghazali
explained that, “‘Aql can encompass a number of meanings…amongst
them are two meanings that are relevant to our discussion: the first refers
to the awareness and recognition of reality…and the second refers to the
grasp of knowledge…in other words, comprehension.”14 Intellect in Islam
holds a high status. It is an indispensable condition for affirming belief
and mandating accountability, the comprehension of knowledge, juridical
reasoning (to deduce legal rulings), and the development and progress of
civilizations.
The ethical principles associated with intellect, in terms of positive
and negative obligations, require that the physician exert his or her utmost
efforts to preserve and advance intellect, while also preventing any harm
from coming to it. Consequently, it is unethical to use any medication that
may potentially damage a person’s intellectual abilities. The patient must
likewise avoid anything that harms his or her intellectual capacity and
must exert effort towards intellectual development and prosperity.
Freedom and independence are central to the intellect. The patient
should not be denied the right to freely decide whether to undergo
12
Al-qāmūs al-muḥīṭ; Lisān al-‘Arab; and Al-mu‘jam al-wasīṭ for the entry of ‘aql.
Abu Hamid Al-Ghazali (1939). Iḥyā’ ‘ulūm al-dīn, (3/4) (Cairo: Matba‘at Al-Halabi);
Ibn Al-Qayyim (n.d.). Miftāḥ dār al-sa‘ādah. Beirut: Dar al-Kutub al-‛Ilmiyah, 1/117.
14
Al-Ghazali, Iḥyā’, (3/4).
13
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treatment or participate in research experiments, provided that his or her
decision does not conflict with an explicit legal text or public interest.
Such cases include when a patient suffers from a serious contagious
disease or when another person may be directly harmed, such as the
enforcement of pre-marital medical check-ups that takes place in certain
countries.
5.4. Principles of Medical Ethics Associated with the Higher
Objective of “Wealth”
These principles are evident in the physician’s or the medical institution’s
requirement to charge patients reasonable fees. Needless to say, exploiting
a patient in order to gain extra money is unethical behavior. Similarly, the
patient should not squander his or her money on extravagant, superfluous
medication. It is also considered unethical for a terminal patient to offer
the physician or other persons money with the purpose of depriving his or
her heirs from their rightful inheritance.
5.5. Principles of Medical Ethics Associated with the Higher
Objective of “Offspring”
The purpose here entails protecting the patient from harm, realizing the
patient’s welfare and interests, and doing our best to avoid any possible
distortion of lineage. Arising from this, abortion is considered an unethical
act with the exception of some cases in which the mother’s life is in danger.
In addition, it is the physician’s ethical duty to preserve lineage during
artificial insemination and any other similar procedures.
5.6. Principles of Medical Ethics Associated with the Higher
Objective of “Honor”
It is not permitted for a physician or institution to act in any manner or
disclose any secrets in regards to the patient that may potentially be disparaging of his or her honor, dignity, or character. On the contrary, the
physician must protect and preserve the patient’s honor and dignity (this
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objective is also related to preserving the patient’s psychological and
emotional well-being).
5.7. Principles of Medical Ethics Associated
with the Preservation of Communities and Societies
This refers to the protection and preservation of public welfare and interests along with individual interests. It requires the protection of a society’s
political, social, economic, and environmental security from any potential
harm or malfeasance. It also requires that medical insurance be distributed
equally and justly among members of society without any form of discrimination. This has been firmly established as a basic legal right for all
individuals.
Based on this, any practices performed by the physician (or the
medical institution), whether for treatment or research, must be intended
to increase benefit, not harm. Therefore, any action that results in the
overall corruption of the society and the environment or leads to injustice
and inequality is considered an unethical act. For this reason, the resolutions issued by the fiqh academies stipulated that DNA fingerprinting,
gene therapy, or the like is permissible only if it does not cause any harm
to humans, animals, or the environment.15 In fact, the preservation of
public interests is prioritized over individual interests. Hence, a patient’s
independent will in rejecting treatment is discounted if he or she suffers a
contagious disease that poses a danger to society.
5.8. Principles of Medical Ethics Associated with the State
This involves the obligation of adherence to the laws and regulations that
have been transparently issued by the state. It includes preserving the
state’s medical and rehabilitation institutions, maintaining its security,
advancing its interests, and protecting it from harm or corruption.
Consequently, any action practiced by the physician that contradicts the
15
See Al-Qaradaghi (2010). Haqībat tālib al-‘ilm. Beirut: Dar al-basha’ir al-Islamiyah,
1/190ff.
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state’s established laws and regulations or that places its security at risk is
considered unethical.
6. A Summary of the Link between the Principles
of Biomedical Ethics and the Higher Objectives
of Sharia
This chapter has made evident that the theory of drafting principles of
biomedical ethics based on the higher objectives of Sharia is a comprehensive theory and successfully integrates the four principles of biomedical ethics. As explained, maintaining any of the eight higher objectives
requires two elements: preventing harm and malfeasance and preserving
interests and benefits. These represent two of the four principles in the
principle-based approach. I also found that the principle of respect for
autonomy falls under two of the higher objectives of Sharia, preserving
religion and preserving life. We further found that the principle of justice
falls under the higher objectives of preserving communities and societies
as well as preserving religion.
This theory also encompasses the principle of equality through the
two higher objectives of preserving communities and societies and preserving religion. Likewise was the protection of a person’s psychological
and emotional well-being through the higher objective of preserving
honor and finally the principle of freedom and similar rights through the
higher objective of preserving the intellect. It also covered the internal
attributes of both the physician and the patient such as sincerity, altruism,
and parental compassion, all of which fall under the higher objective of
preserving religion.
There remain three aspects that are needed in order to complete this
theory. They are the binding obligation (ilzāmīyah), normativity
(mi‘yārīyah), and coherence (ḍabṭ). Obligation and commitment have
been addressed through the higher objective of preserving religion, which
makes mandatory the adherence to beneficial medical ethics and prohibits
immoral conduct, as ordained throughout numerous Qur’anic verses and
Prophetic traditions. In turn, it becomes the responsibility of the individual
to abide by these ethics and the responsibility of the state to decree
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Formulating Ethical Principles 331
binding legislations in order to regulate those medical ethics that impact
other persons.
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7. Normativity and Coherence
Although the aforementioned eight objectives and the principles of biomedical ethics already have a coherent relationship, this coherence may
be enhanced and a more comprehensive framework can be developed
through utilizing a set of legal maxims that serve to outline issues of harm,
interest, and the balance between them. These rules are as follows:
7.1. Governing Legal Maxims for Issues of Harm
Islamic law provides a set of governing legal maxims or rules, deduced
from the legal texts (the Qur’an and Prophetic tradition), that facilitate our
development of a consistent framework in this regard. These governing
rules include the following:
(i) The rule, “There should be neither harming nor
reciprocating harm”16
This rule is a Prophetic narration (hadith) whose chain of narrators was
deemed “acceptable” (ḥasan) by many scholars and “authentic” (ṣaḥīḥ)
by others.17 This hadith indicates that it is prohibited to cause any harm
and that harm is not to be removed by way of another harm. A set of rules
has been derived from this Prophetic narration such as: harm is to be
removed, harm is not to be removed by way of harm, necessity renders the
prohibited permissible, need is treated as necessity, necessities and needs
must only be assessed and answered proportionately, hardship begets
facility, and if a matter is difficult, ease it.18
16
The hadith reads, “Let there be no harm or reciprocating harm.” It was narrated by Malik
in Al-muwatta’ from Abu Hurayrah.
17
Ibn Rajab (2001). Jāmi‘ al-‘ulūm wa-al-ḥikam. Mu’assasat al-Risāla, 2/211.
18
See Al-Suyuti (2004). Al-ashbāh wa-al-naẓā’ir. Cairo: Dar al-Salam, 1/210–218; Ahmad
Al-Zarqa’ (1989). Sharḥ al-qawā‘id al-fiqhīyah. Damascus: Dar al-Qalam, 525–830.
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There are some other maxims related to this hadith or general rules,
including “Whatever is permissible because of a certain excuse ceases to
be permissible with the disappearance of that excuse”, “When what makes
something forbidden no longer exists, what is forbidden shall return [to
permissibility]”, “A private harm is tolerated in order to ward off a public
harm”, “Minor damage will be endured to get rid of major damage”, “In
the presence of two evils, the one whose harm is greater is to be avoided
by the commission of the lesser”, “The lesser of the two evils is tolerated”,
“Warding off harm should always take priority over the accruement of
benefit”, “Harm is to be removed as much as possible”, “Necessity does
not invalidate the right of others”, “Harm is to be warded off whether
intended or not”, “Harm is to be warded off as much as possible”, and
“Necessity is only considered when it is real and certain and not when it
is conjectured.”19
(ii) The rule, “Certainty cannot be overruled by doubt”
In the case of treatment, if there is certainty, positively or negatively, this
certainty should not be dispelled by doubt, and it is not allowed to neglect
such certainty. For example, if there is definite evidence that a particular
treatment will be of no avail for a particular disease, it is not allowed to
neglect this certainty unless we reach a different conclusion based on
another certainty, which would in turn be based on proofs that impart
certainty.
The following rules are related to this maxim: “The basic principle is:
what has once existed is [deemed] as continuing,” and, “The basic nature
of things is permissibility.” Imam Al-Shafi‘i once said, “The fundamental
principle upon which I base my decisions is that I use certainty, abandon
doubt, and do not make use of conjecture.”20 We also have the following
rules: “The basic principle is to ascribe the event to the nearest time of
occurrence,” and, “The original rule for all things is permissibility.”21
19
Al-Suyuti, Al-ashbāh wa-al-naẓā’ir (1/173); Al-Zarqa’, Sharḥ al-qawā‘id al-fiqhīyah,
113–164; Ali Ahmad Al-Nadwi, Mawsū‘at al-qawā‘id wal-ḍawābiṭ, (2/220–223).
20
Al-Suyuti, Al-ashbāh wal-naẓā’ir, (1/156).
21
Ibid. (1/151–168); Al-Zarqa’, Sharḥ al-qawā‘id al-fiqhīyah, 35–64.
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8. How Should a Physician or Patient Decide Regarding
Treatment or Research Experiments?
As discussed earlier, medication must be used with the purpose of advancing interests or preventing harms. This raises the question: Is certainty
in regards to resulting benefits and/or harms a condition for decisionmaking? The answer is as follows:
The second rule mentioned above (“Certainty cannot be overruled by
doubt”) refers to situations of absolute certainty, which may only be
negated by opposing absolute certainties. However, in cases lacking absolute certainty, the required condition is ensuring the existence of a predominant hypothesis based on professional principles as to whether
treatment should be pursued or not. According to Al-‘Izz bin ‘Abd
Al-Salam: “Efforts exerted to achieve the interests of this world and the
Hereafter and warding off their evils are usually based on a preponderant
presumption.”22 He also stated, “Because the preponderant presumption
comes true in most cases, the interests of this world and the Hereafter
have usually been estimated by this means …So, it is not allowed to disrupt the interests that will most likely come true for fear of any banes
whose occurrence is not guaranteed.”23 He then asserted that it is not
permissible to act based on arbitrary assumptions. Rather, assumptions
are classified into three categories: low-ranking assumptions, highranking assumptions, and middle-ranking assumptions.24 Furthermore,
Islamic law established a firm rule that explicitly erroneous assumptions
are to be disregarded.25
It is not difficult to arrive at an acceptable level of assumption.
In fact, it is quite possible to attain this through knowledge, experience,
experimentation, and consultation. Imam Al-‘Izz claims that, “Most of
the elements of benefit and harm in this world can be identified by means
of human discretion.”26 He continues, “Some beneficial and harmful
issues can be recognized by both intelligent and unintelligent individuals,
22
Ibn ‛Abd al-Salām (n.d.). Al-qawā‘id al-kubrá (Qatar Ministry of Religious Endowments) (1/6).
Ibid. (2/35).
24
Ibid.
25
Al-Suyuti (2004). Al-ashbāh wal-naẓā’ir (1/343).
26
Ibn ‛Abd al-Salām (n.d.). Al-qawā‘id al-kubrá (1/7,13).
23
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while others are only discernible to intelligent individuals.”27 Hence, the
formation of specialized committees that are qualified to make appropriate decisions for complicated situations is imperative.
9. Applying Fiqh of Balances in Decision-Making
for Contradicting Cases
The fiqh of balances (fiqh al-muwāzanāt) plays a central role in cases
where a conflict arises between benefits and interests themselves, damages and harms themselves, or between benefits/interests on one hand and
damages/harms on the other hand. In these cases, decisions should be
made by balancing between the quest to achieve the best, strongest, and
most effective benefits and to prevent the most and worst harm and detriment.28 For situations in which the benefits of a certain action are equal
to those of inaction, after consultations and recommendations from relevant committees, the final decision is up to the physician’s discretion.
If equality, however, is not determined, the issue should be referred to
another committee for the decision to be made, while practicing caution
and emphasizing potential harm and detriment as much as possible.
The Muslim Physician’s Oath adopted by the Islamic Organization
for Medical Science (IOMS) during its first conference held in Kuwait in
1401 A.H. (1981 C.E.) emphasized the importance of promoting interests
and preventing harms as illustrated below.
In the name of God, The Most Gracious, The Most Merciful,
I swear by God … The Great
To regard God in carrying out my profession
To protect human life in all stages and under all circumstances, doing
my utmost to rescue it from death, malady, pain and anxiety
To keep people’s dignity, cover their privacies, and lock up their secrets
To be, all the way, an instrument of God’s mercy, extending my medical
care to near and far, virtuous and sinner and friend and enemy
27
28
Ibid. (1/38).
Ibn ‛Abd al-Salām (n.d.). Al-qawā‘id al-kubrá (1/8, 87).
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Formulating Ethical Principles 335
To strive in the pursuit of knowledge and harness it for the benefit but
not the harm of Mankind
To revere my teacher, teach my junior, and be brother to members of the
Medical Profession joined in piety and charity
To live my Faith in private and in public, avoiding whatever blemishes
me in the eyes of God, His apostle and my fellow Faithful.
And may God be witness to this Oath.29
10. The Broad Scope of Medical Ethics that Includes
Physicians, Patients, and Others
Medical ethics must primarily stem from the physician himself. These
ethics should be inherent qualities in his relationship with the patient since
medicine is a means, not an end, for healing a patient. The healing of a
patient is the principal end. Therefore, a physician’s care for his patients
must be unparalleled in its excellence. Likewise, the physician must maintain positive relationships with his colleagues, institution, and society.
Given the significant role played by a physician, maintaining the following fundamental ethics and guidelines are crucial:
10.1. The Ethics of a Physician: Guidelines and Behaviors
Islamic Sharia has established a set of distinguished ethics (guidelines,
rules, and behaviors) for the physician who treats people whether physically, psychologically, or otherwise. Below is a brief outline of these ethics:
First: The physician must be knowledgeable, experienced, and proficient
in his or her medical profession. In our present day, it is also necessary for
him or her to obtain a medical degree and an official license from the
country in which he or she will be practicing (a condition acknowledged
by Sharia).
Second: The physician’s practice must be in alignment with the commonly
agreed upon professional regulations.
29
The English text is taken literally from the official translation. See Islamic Code of
Medical Ethics. Kuwait: International Organization of Islamic Medicine, 1981: 93.
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Third: The physician must be sincerely dedicated to his or her work,
trustworthy, protective of the rights of others, and striving towards
excellence and innovation.30
These are the three fundamental conditions in Islam. They can be summed
up using two words: sincerity (ikhlās) and professionalism (ikhtisās). This
was reiterated by numerous verses throughout the Qur’an. For instance, in
one verse it is stated, “…‘Indeed, the best one you can hire is the strong
and the trustworthy’” (Qur’an 28:26). In this context, strength refers to
professionalism and experience while trustworthiness refers to sincerity
and honoring confidentiality.
Fourth: The physician should be knowledgeable of the legal rulings associated with medicine and treating patients.
Fifth: The physician should be characterized by Islam’s noble attributes,
particularly:
(i) God-consciousness, fear of God, and cognizance of God’s presence
throughout his or her treatment of a patient. The physician should be
as the Prophet Muhammad (PBUH) described, “To worship God as if
you see Him, and if you do not achieve this state of devotion, then
(take it for granted that) God sees you.”31
(ii) Humility towards God, patients, and colleagues and practicing virtue
in all interpersonal relationships.
(iii) Truthfulness and absolute honesty in regards to sight, behaviors,
integrity, and chastity. In addition, to refrain from cheating, betrayal,
envy, malevolence, and all other diseases of the heart.
Sixth: The physician should respect his medical specialization through
enhancing his interest in and study of the field and pursuing creativity and
innovation. He should also respect other specializations, meaning he
should not treat a disease that is beyond his area of expertise but rather
30
For more information, see relevant papers presented by Ali Dawud Al-Jaffal, Ahmad
Raja’i Al-Jindi, Abdul Sattar Abu Ghuddah, Muhammad ‘Atta Al-Sayid, Muhammad Ali
Al-Bar, Mustafa Abdul Ra’uf, Su‘ud Al-Thubayti published in Group of Scholars (1993).
Islamic Fiqh Academy Journal, issue 8 (3/10–407).
31
Bukhari, Kitāb Al-Īmān (no. 4777) and Muslim, Kitāb Al-Īmān (no. 9), on the authority
of Abu Hurayrah.
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Formulating Ethical Principles 337
refer the patient to the appropriate physician or seek advice from the relevantly specialized physician. Respect for other specializations also
entails that the physician refrain from practicing any profession that may
conflict with his medical profession, such as simultaneously working at a
pharmacy.
Seventh: The physician should honor medical confidentiality and abide by
the ethical and humanitarian values ratified by Islam. In other words, the
temptations of wealth, authority, and desires in this world should never
affect his integrity. He should live his life committed to these superior
values and not allow his conscience to be bought with anything this world
can offer. This includes even the simplest of transgressions such as granting undue medical leaves or submitting false reports. This is a great
responsibility that falls on the shoulders of physicians and all those working within similar professions.
Eighth: The physician should be keen on curing the patient and should not
prevent treatment except in cases where there is a legal or scientific justification. In turn, a physician is in no way permitted to participate in ending a patient’s life.
Ninth: The physician may not conduct any experimentation on his patients
without the patient’s consent or without the approval of the specialized
authority.
Tenth: The physician must adhere to the laws, systems, regulations, and
medical decisions issued by the specialized authorities serving to regulate
matters of private and public health. This falls under the Islamic legal
obligation of obeying those in authority as long as it does not conflict with
any of the Sharia texts. As commanded by God, “O you who have
believed, obey God and obey the Messenger and those in authority among
you…” (Qur’an 4:59).
These are the 10 commandments that physicians must adhere to. They
are considered a code of conduct for the medical profession and the solemn covenant (al-mīthāq al-ghalīz). They represent a binding contract
and a mandatory commitment that God has commanded us to fulfill in His
orders, “O you who have believed, fulfill [all] contracts…” (Qur’an 5:1)
and, “…And fulfill [every] commitment. Indeed, the commitment is ever
[that about which one will be] questioned” (Qur’an 17:34).
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11. Confidentiality
Although confidentiality is included in the abovementioned 10 commandments, it is necessary that we discuss it further due to its particular significance. It is also often referred to as medicine-related confidential
information or medical profession privacy. This ethical value implies the
necessity of maintaining confidentiality regarding all matters seen or
heard by the physician from the patient. The physician must not disclose
any secret that may harm the patient or any related party. The scope of this
concept extends to all the information related to the patient’s health, personal history, sexual relations, and so forth.
Religion has categorically prohibited every type of transgression
against a person’s honor as it has equally prohibited transgressions against
life and wealth. Basically, causing any undue harm to any human being is
religiously forbidden. Therefore, disclosing confidential information is
prohibited by the Sharia and is both professionally and legally liable.
Further, this action is considered a betrayal of trust and hence is not a trait
of true believers. Rather, God describes true believers as, “And they who
are to their trusts and their promises attentive” (Qur’an 23:8). Furthermore,
Prophet Muhammad (PBUH) identified betrayal of trust as one of the
signs of hypocrisy.32
Safeguarding a patient’s secrets is an integral part of all human values
and is reinforced by all divine religions. Even the ancient oath of
Amenhotep, one of the Ancient Egyptian pharaohs, included the statement, “Whatever I hear in my profession or outside of it which should not
be disclosed, I will never reveal.”33 Following this came the Hippocratic
Oath, taken by medical graduates to this day, which includes, “Whatever,
in connection with my professional practice or not, I see or hear, in the life
of men, which ought not to be spoken of abroad, I will not divulge, as
reckoning that all such should be kept secret.”34
32
The text of the Prophetic narration states, “Signs of a hypocrite are three: If he speaks,
he tells a lie; and if he promises, he breaks his promise; and if he is entrusted, he betrays
[proves to be dishonest].” See Bukhari, Kitāb Al-Īmān (no. 33) and Muslim, Kitāb Al-Īmān
(no. 59), on the authority of Abu Hurayrah.
33
Al-mawsū‘ah al-tibbīyah al-fiqhīyah, 556.
34
Ali Dawud al-Jaffal (1993). Phyician ethics (Akhlāqīyāt al-tabīb). Islamic Fiqh Academy
Journal 8(3): 17–18.
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Formulating Ethical Principles 339
Early Muslim physicians similarly underscored the importance of
confidentiality. In his book The Best Accounts of the Biographies of
Physicians (‘Uyūn al-anbā’ fī tabaqāt al-atibbā’), Ibn Abi Usaybi‘ah
highlighted some of the oaths taken by the physicians of his era such as,
“Those things that I see or hear while treating patients or at other times,
which should not be disclosed, I refrain from talking about.” He also mentioned some ethics associated with physicians including “perfect morality,
sound mind, safeguarding patients’ secrets, knowledge of Islamic law,
avoiding the practice of abortion, and other similarly admirable behavior.”35
Islam has prohibited disclosing secrets (except in cases of necessity
with specific guidelines) due to the potentially harmful psychological,
moral, physical, and financial consequences. In fact, breaching medical
confidentiality is harmful to the medical profession itself. If a patient loses
confidence in the physician, he may not reveal all the information regarding his condition, which may in turn obscure discovery of the actual disease. Islam places a strong emphasis on the issue of trustworthiness to the
extent that a person is obligated to conceal what was said during a gathering if the other party indicates a desire for concealment. In this regard, it
has been narrated that the Prophet (PBUH) asserted, “When a man tells
someone something and then departs, it becomes a trust (amānah).”36
This Prophetic narration clearly highlights that gatherings are considered
trusts and that the one you consult is considered a trustee.
In its eighth session, the International Islamic Fiqh Academy issued
resolution No. 79 (10/8) concerning the necessity of maintaining confidentiality in all medical professions except under exceptional cases. The
exceptions under which confidentiality may be breached are:
• In cases where public interests will be preserved.
• In cases where public harm will be prevented.
The exceptional cases under which a breach of confidentiality is
acceptable must be clearly stipulated in the codes of professional practice
for the field of medicine as well as other professions.37
35
‘Uyūn al-anbā’ fī tabaqāt al-atibbā’, (1/35).
Narrated by Tirmidhi, no. 1882.
37
See Group of Scholars (1993). International Fiqh Academy Journal 8(3).
36
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May 2, 2013
14:6
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Script of Oral Discussions
(Day 3, Session 3)
After Ali Al-Qaradaghi presented his paper, the following discussion
took place.
Abdullah Bin Bayyah
Everything we have heard so far is good, and in my opinion it is all complementary and free of contradiction. A document on ethics can be drafted
out of our discussions, starting with broad principles followed by more
particular issues like those outlined by Sheikh Al-Qaradaghi. This would
be a very important document that could be of added value for doctors
and parties responsible for drafting laws. These parties need intellectual
and academic support to enable them to enforce these laws and to guide
them to make the right decisions. Likewise, doctors need academic ethical
documents that are in compliance with their convictions and their ethical
and religious consciences.
There is nothing new that I would like to add to what my colleagues
have already presented. The way I see it, the higher objectives are a field
or garden for rulings and ethics are the fruits that the rulings produce.
Now the soil is ready, the field is ready, and the trees are being planted;
therefore, the fruits will be the noble ethics by which everyone should
abide.
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However, if you plan to write a report or document, you should also
address other groups besides the doctors, such as pharmaceutical companies, insurance companies, and governments. You should advise these
parties to limit their greediness and focus instead on the humanitarian
dimension of providing assistance to people. This is especially relevant in
countries that lack drugs for AIDS and other drugs due to the positions
adopted by certain greedy pharmaceutical companies. How can we discuss ethics while neglecting to talk about those who deny people access
to the drugs they need? Preventing drugs that are known to be effective
from people who need them is like denying people food and water. It is
not acceptable.
Finally, I would like to say that in many cases a doctor faces a situation where he must intervene. This puts him in a delicate situation because
intervening when someone’s life is in danger is obligatory according to
Sharia. Thus, the role of a doctor is central in this regard. The responsibility a doctor has in front of God is immense. Indeed, the medical profession is an incredibly honorable one and the doctor is rewarded for his
work. Before a doctor is dealing with patients, he is dealing with God
Almighty.
Mohammed Ghaly
Do you have any comments about the inclusion of two new higher objectives of Sharia by Sheikh al-Qaradaghi, namely, the security of the society
and the security of the government, especially as far as it relates to medical ethics?
Abdullah Bin Bayyah
The security of the society and the security of the government are certainly important to the matter at hand but are not at the heart or core of it.
Our discussion is about biomedical ethics, and each party should do its
role. Governments should pass the appropriate laws, doctors should
uphold them in their profession, pharmaceutical companies and insurance
companies should operate according to these ethics, and so on. Even in the
face of difficulties or perceived risk, every party should hold fast to the
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Script of Oral Discussions (Day 3, Session 3) 343
pertinent ethical values such as justice, mercy, etc. These are major
principles, but they encompass minor principles or minor objectives.
I often liken the higher objectives to a ladder, the highest rung of
which is the grand higher objectives (maqāsid kullīyah kubrá). Al-Shatibi
says there is no higher degree above them and they govern all comprehensive principles (kullīyāt), including Islamic legal theory (usūl al-fiqh). The
second rung includes the three categories: the necessities (darūrīyāt),
needs (hājīyāt), and luxuries (tahsīnīyāt). To repeat, we have at the top of
the ladder the grand higher objectives. Then in the middle of the ladder
we have the higher objectives that are comprehensive (kullī) with respect
to what is below them and particular ( juz’ī) with respect to what is above
them. And so on until you reach the lowest level of the ladder.
Mohammed Ghaly
Are the higher objectives that Sheikh Al-Qaradaghi mentioned considered
among the category of grand objectives (al-kullīyāt al-kubrá)?
Abdullah Bin Bayyah
The higher objectives that Sheikh Al-Qaradaghi mentioned are among the
necessities, which are those things whose preservation both on the individual and collective levels are necessary for a human society to exist.
Scholars cite this as one of the reasons they were called “necessities.” The
other reason they were called “necessities” is because they were known
from the religion by necessity or by default (‘ulimat min al-dīn bi-aldarūrah). And God knows best.
Hassan Chamsi-Pasha
We have nowadays the concepts of public health ethics and community
medicine. Community medicine is not always conducted by physicians; it
may be conducted by medical professionals and others who administer
preventative medications, for example. So the field of medicine is expanding to encompass community medicine, which is included among the
areas to which medical ethics apply.
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Jasser Auda
Regarding the categorization of the higher objectives of Sharia, we cannot
add to them except what is of their kind. The higher objectives include
things like honor and wealth, etc. Adding things [explicitly] related to the
society or government would be adding things of a different type altogether because the higher objectives are related to the needs of the human
[as an individual]. Ibn ‘Ashur had a perspective on this. He delineated
within each of the five or six higher objectives two dimensions: one
related to the individual and the other related to the society. So we can add
a societal dimension to the preservation of life, of honor, of wealth, etc.
For example, when it comes to the higher objective related to [the societal
dimension of] the preservation of life, we can talk about public health.
When it comes to honor, we can talk about human rights in general. By
expanding the current higher objectives to the level of society we avoid
introducing new higher objectives that are not of the same type and thus
do not belong in the same category.
Abdullah Bin Bayyah
The higher objectives of Sharia are unrestricted and can always be added
to. Any instance in which God says in the Qur’an that, “God wants…” or,
“In order not to…” or anything that indicates a purpose or goal, whether
in the positive or the negative sense, counts as a higher objective. In his
book The Conclusive Argument from God (Hujjat Allah al-bālighah),
Wali Allah unearthed a treasure of higher objectives. He included as
higher objectives everything that could ever be imagined as such from
references in the Qur’an and the Prophetic tradition. The higher objectives
are in fact in every ruling of Sharia, whether it relates to a specific ruling,
to a reason behind a ruling, or to a comprehensive ruling. So certainly no
one can say that the higher objectives have all been found; they are unrestricted in number. However, the well-known set of five higher objectives
[preserving religion, life, intellect, offspring, and wealth] will remain
distinct because this set is comprehensive and complete.
“…Unquestionably, His [God’s] is the creation and the command…”
(Qur’an 7:54). There is wisdom behind every single cell He has created in
this universe, and likewise there is wisdom behind every single ruling He
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has commanded Thus, I think these [five] higher objectives should be kept
as they are, and we can downstream them to the rest [and in this sense
consider them to be comprehensive and all-inclusive].
Abdul Sattar Abu Ghuddah
I wrote a research paper entitled, “Sharia-Based Principles for the
Profession of Medicine and Medical Treatment” (Al-mabādi’ al-shar‘īyah
lil-tatbīb wal-‘ilāj). The paper included a number of legal maxims relevant to the medical field, e.g. the maxim of necessities, the maxim of
[avoiding] harm, the maxim of (taking) permission, the maxim of cultural
norms, and others. If you find it is suitable, it can serve as the introduction
to the process of practical application after we come up with what corresponds to the four principles on a theoretical level. In fact, some of the
maxims may already correspond to the four principles.
Ahmed Raissouni
Our main focus is deducing some of the comprehensive principles (kullīyāt)
or rules related to biomedical ethics and basing the process of deduction
upon the higher objectives of Sharia. I agree with linking biomedical ethics
to the first three necessities, which are the preservation of life, of offspring,
and of intellect. It is clear that the development of the principles of biomedical ethics should be based on these three necessities in particular, and
there is no exaggeration in doing so. Sheikh Al-Qaradaghi mentioned this
clearly and presented practical examples of their application.
As for linking biomedical ethics with the rest of the necessities, that
would entail a certain degree of exaggerative interpretation, unnecessary
complications, and unreasonable generalizations. A better approach would
be to choose from the higher objectives or necessities those that are relevant to medicine, and I think Sheikh Al-Qaradaghi is more inclined to this
approach as well. Dr. Chamsi-Pasha touched on this: instead of talking
about the security of the state and society, we will go straight to community medicine and what it requires in terms of laws and measures.
In regards to the issue of the higher objectives of Sharia in general,
I agree with Sheikh Bin Bayyah and Dr. Auda that the five necessities
were crafted on the basis of certain premises or were meant for certain
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purposes. We can add as many higher objectives as we want. This is
because the needs of individuals and of societies are abundant and cannot
be limited, meaning that some of them may become necessities though
they were not previously considered as such. Therefore, the door is open.
However, after many years of contemplating the idea, I do not think we
should add anything to the set of five higher objectives of Sharia. This is
because if we did, the addition would be of a type different from that of
the five higher objectives.
The preservation of honor (‘ird) is sometimes counted as the sixth
higher objective, but I believe it is not essential. The agreed-upon higher
objectives of Sharia are five [the preservation of religion (dīn), life (nafs),
intellect (‘aql), offspring (nasl), and wealth (māl)]. Muslim scholars like
Ibn ‘Ashur — and I agree with him — stated that the preservation of
honor complements the preservation of offspring. Some Muslim scholars
would replace the preservation of offspring with the preservation of lineage (nasab) in the set of five higher objectives of Sharia. However, others
have objected by saying that lineage is not among the necessities but
rather is among the needs; they raised the question, where is the necessity
of people knowing that so-and-so is the son of this person or that? It is an
important issue but is counted at the level of needs and not necessities;
everything should be given proper prioritization.
The early scholars used to derive the necessities from the prescribed
legal punishments (hudūd) and penal law (‘uqūbāt). However, they used
to cite short examples in which they hastily made these connections, without giving detailed reasoning or consideration to the matter. To be honest,
that did not do justice to the necessities, and this is why Ibn ‘Ashur
refused the idea of making a direct link between the necessities on the
one hand and the prescribed legal punishments and penal law on the other.
The necessities are much broader than the penal law, and there are things
more important than the penal law for preserving these necessities, especially as far as the positive obligation (al-hifz al-wujūdī) is concerned.1
1
Editor’s note: Al-ḥifz al-wujūdī entails taking measures to ensure that a particular higher
objective is indeed preserved or upheld (e.g. facilitating learning and education for preservation of the intellect), while al-ḥifz al-‘adamī entails taking measures to ensure the
higher objective will not be harmed (e.g. prohibiting alcohol and other intoxicants for
preservation of the intellect).
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Script of Oral Discussions (Day 3, Session 3) 347
Positive obligation is the basis, and negative obligation (al-hifz al-‘adamī)
complements and protects the bare minimum level of preservation (al-hifz
al-darūrī). Positive obligation does not entail punishments in the first
place, and this is why Al-Shatibi and others said, “These necessities have
been arrived at by means of induction (istiqrā’),” and when we say induction, it means that each one of these necessities was arrived at by the
examination of hundreds of texts and rulings. We need to get past the
claimed link between the necessities and the penal law because we now
have the ability to study the necessities and their sources in a much more
comprehensive way.
As mentioned by Sheikh Al-Qaradaghi and supported by Sheikh Abu
Ghuddah, the maxims related to the two concepts of harm and necessity are
intimately related to the lives, bodies, and needs of human beings. These
maxims themselves include what we can call “mothers” and “daughters.”
We start with the [broad] rules that state, “There shall be no harm nor
reciprocating of harm,” “harm is to be removed,” etc. From those, other
subrules are derived, from which we choose the most overarching and
essential with respect to the medical field.
Hassan Chamsi-Pasha
The book I wrote with Dr. Al-Bar contains a chapter on the juristic rules
of medicine, and we included two or three examples of practical applications under each rule so that the issues could be relevant and clear to
physicians. We mentioned a total of 20 rules.
Ali Al-Qaradaghi
We all agree to compose biomedical ethics from the higher objectives of
Sharia, whether from all or some of them. This requires a practical workshop that will deal specifically with this topic without touching upon
topics of indirect relevance. I recommend we conclude this session and
begin organizing a workshop incorporating what was said during the
seminar — whether it was about three higher objectives, eight higher
objectives, etc. I can present a group of recommendations to you all and
then we can elaborate on them, mentioning the rules we alluded to in the
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seminar as well as from previously written books or studies. We can make
this into a document or report, and in that way we will have presented a
core text. The document should be written in a rigorous, legal style and
should be constrained to a couple of pages. After that, it may be expanded
upon by explanations and mention of practical applications in the scope
of medical professionals, insurance companies, etc.
Mohammed Ghaly
As I was re-reading the submitted papers, I began to develop a modest
conception that I would like to propose to you for feedback. The concept,
as Sheikh Bin Bayyah illustrated, is in the form of a pyramid divided into
top, middle, and bottom sections. Based on my readings and the ongoing
discussions, the summit of the pyramid consists of the higher objectives
of Sharia. These higher objectives can indeed be applied to biomedical
ethics, and it appears there are no objections to doing so. The prevailing
opinion seems to be that applying the higher objectives of Sharia to biomedical ethics is actually the best approach, as it would be rooted in the
Islamic tradition and thus would likely not trigger a lot of debates about
its Islamic character.
Following the higher objectives of Sharia, which are at the top, we
arrive at what is more specific or detailed in the middle. I will now mention these specifics without ordering them in terms of priority and will
leave it to you to re-arrange them as you see best. Let us talk about the
ethics that will fall under a certain higher objective. For example, we can
take the higher objective of preservation of life, assuming we find it relevant and applicable to the field biomedical ethics in Islam. We find under
it a set of ethics related to the physician, the patient, and so on, and those
ethics are directly related to the preservation of life. We put these under
the higher objective.
What also come under this higher objective are the juristic rules or
Islamic legal maxims — that are used to rigorously determine the
method(s) of applying the higher objectives on the medical issues that we
are dealing with. [This is especially important] because it is clear that one
of the problematic areas of the four principles approach in the West has
to do with specification and the application of these four principles to
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Script of Oral Discussions (Day 3, Session 3) 349
individual cases. So under this higher objective [the preservation of life],
we have a certain number of rules. If we wanted to apply these rules to
some particular situations, then the juristic rules will determine the
method(s) of application.
To clarify: we have the ethical principles under the higher objectives;
the juristic rules [that aid in the method(s) of application to specific cases]
under the higher objectives; and perhaps we also have specific examples
of juristic rulings. As Sheikh Al-Qaradaghi mentioned, some examples
are cloning and organ donation. In this way, when the physician looks
into the higher objectives and the ethics, they will not remain vague generalizations, and it will be easier to apply the higher objectives on individual cases.
I also want to touch upon the inclusion of the four principles in our
endeavor. For example, we can say that under so-and-so higher objective
and such-and-such principles, the principle of autonomy is included but
with certain limits. It is not an open-ended inclusion; rather, we are bound
by the higher objectives, the principles, and the governing ethical laws of
Islam. So we will have to pay attention as to where to put and how to
include the four principles.
As we lay down the higher objectives and what comes under them, we
must consider who exactly will be the ones applying these ideas to specific situations. They will not always be physicians. There may be other
stakeholders such as ethics committees, legislators, insurance companies,
pharmaceutical companies, or individuals concerned with public health.
It is critical we discuss the qualifications and credentials of different
implementing parties in more detail. We have been discussing theories,
and I hope we can work on papers and workshops that address the details
of implementation.
Annelien Bredenoord
If you were to formulate the principles of Islamic bioethics and also formulate more specific rules, how would you position them? Would they be
a particular set of ethical guidelines for the Islamic world? How would
you position the Islamic medical ethics in relation to the four principles
and in relation to people living in other parts of the world? I am asking
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this because, once again, if we discuss universality then it should be
formulated in a manner that it can be shared by all of us. Is that your aim
and if not, then what is the aim?
Ali Al-Qaradaghi
Al-Shatibi stated that these five necessities are part of general religion,
meaning you will not find two people who differ on that matter. They are
shared by all religions and are inherent to our natural disposition (fitrah).
So we take these five necessities as our starting point and sometimes use
the specifics of Islam to elaborate and shed further light on them. So they
are a healing and mercy to all of mankind and are universal in their nature.
In the case there is something specific to Islam that we think may be of
benefit to others, we are happy to present it to them.
Mohammad Ali Al-Bar
How can we apply the four principles to specific cases outside the [cultural and philosophical] settings in which they originated? For example,
we have different understandings of autonomy. How can we harmonize
ideas from different cultural perspectives? There is difficulty in the
connecting or joining of ideas that — while they do agree in many
regards — are perhaps not similar enough to the point that they can be
linked in the same intellectual pyramid.
Mohammed Ghaly
Of course it is a difficult task, but we need to challenge our [Islamic]
scholars in this regard. I think Sheikh Al-Qaradaghi did try in his paper.
For example, he placed the principle of autonomy in the scope of one of
the higher objectives of Sharia, namely the intellect (‘aql).
Jasser Auda
I suggest the pyramid be turned into a network because, in my view, the
problem with the pyramid is its vertical structuring of ideas. A network,
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on the other hand, connects ideas across the board, which better reflects
the situation here.
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Hassan Chamsi-Pasha
Who is the target audience for these principles of medical ethics and bioethics? Are we addressing all doctors around the world or only Muslim
doctors as a first phase? I would say we should focus on the Muslim doctors at first because, to be honest, I can tell you as an example that many
doctors I have interacted with in Saudi Arabia do not immediately see the
significance of the field of medical ethics or do not have a complete
understanding of medical ethics.
So it is important we specify our objective. It is no doubt that Islam
is a message for all mankind, but I think we have two objectives here.
The immediate objective is to reach out to all Muslims doctors and
encourage them to become familiar with Islamic knowledge in order to
be able to practice their profession in line with the Islamic understanding
of their field. Our other aim is to reach out to all of humanity and to all
doctors around the world. I do not think that Beauchamp and Childress
expected their book would reach a global audience — at the time they
wrote it, perhaps they were addressing the American public — but eventually it did.
Tariq Ramadan
My understanding of our purpose here — and more generally at the
research Center for Islamic Legislation and Ethics — is to discuss Islamic
legislation and ethics from the inside, from an Islamic framework. We are
not addressing the West; we are addressing ourselves first, from an
Islamic point of reference. After that, we engage in dialogue with the West
so that the issues may be understood from an Islamic point of reference.
So the question is not who to address; rather, it is about the importance of
approaching the issue through an Islamic framework. In so doing, we are
not addressing Muslim doctors only; we are also addressing non-Muslim
doctors so that they may understand the Islamic point of reference.
I would like non-Muslim doctors to read this and realize that within the
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agreement between us.
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Hassan Chamsi-Pasha
I agree we should start with ourselves. We should deliver this message to
Muslim doctors first since they are the ones most likely to use these rulings in their profession. We need them to be exemplars in the application
of Islamic ethics in the medical field — indeed, what we lack is the practical application. I think this is an important part of our objective, and after
that the message will spread to the rest of the world.
Ahmed Raissouni
There is not a big difference between addressing Muslims and addressing
non-Muslims. Perhaps we would use clarifying terms when addressing
the latter, but the core ideas are the same. Regarding structure, the two
methods of using a pyramid and using a network are both possible. It is
hard to tell now what the structure will end up being; upon formulation it
will be clear which structure is most suitable.
Mohammed Ghaly
When Beauchamp and Childress wrote their book about the four principles,
they did not read about Islam, although they have studied theology. They
studied Christianity and perhaps they knew about Judaism, but I do not
think they had much knowledge about Islam, Buddhism, or other religions.
As Dr. Beauchamp mentioned and as we discussed in detail, the principles
emerged from Western backgrounds and philosophies — Western in their
founding, their form, their development, etc. However, this did not to prevent him from putting his ideas out for everybody.
My point is that “universality” does not at all mean separating ourselves from locality and from immersion in tradition. On the contrary: it is
this immersion that leads to universality. If the four principles were identical [to what we have], we would have ended our discussions on the first
day. In order to get to a point where we can address everyone, we must
delve deep into our tradition and heritage so that we can come up with
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Script of Oral Discussions (Day 3, Session 3) 353
something of an Islamic nature. From this we extract what we believe is
universal about it, which we introduce to the world, and then it is up to
each person to decide whether or not to embrace it.
I believe the most important goal is to contribute an Islamic perspective. A big concern nowadays in both the East and the West is that we need
governing principles in bioethics so that doctors practice their profession
ethically because otherwise humanity will be lost. Bioethics is being discussed all around the world, and Islam should have an input. That does not
mean rejecting others or simply keeping to ourselves; rather, it means we
deeply examine the Islamic tradition in order to create something rooted
in the Islamic tradition. Through our religion we know what is universal
to humanity and what is exclusive to Islam and Muslims. For example, the
ritual acts of worship like prayer and fasting are not expected of those who
do not believe in Islam, and likewise certain Islamic rules cannot be generalized to all of humanity. However, other things are indeed universal, so
we take from these.
We should start with doctors in the Islamic world as a matter of necessity. The West will be all right if they are not provided with our Islamic
biomedical ethics because they already have biomedical ethics. Our biggest duty is towards our doctors because their general understanding of
biomedical ethics is lacking in the first place.
Mohammad Ali Al-Bar
In addition, we should remember there are a large number of Muslim doctors in the West.
Mohammed Ghaly
Yes, and there are also many Western doctors in the Muslim world. There
are also Muslim patients in the West who interact with doctors there.
Tariq Ramadan
I want to say that there is a big difference between initiating and responding.
Are we presenting something, or are we responding to the West? We want
the basis for our discussion to be that we are presenting something.
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Annelien Bredenoord
Dr. Ramadan, I understand that you want an introduction rather than a
response, but it is almost unavoidable that there is some kind of response
because you already took notice of concepts developed in other parts of
the world. So just a pure introduction without seeing what others have
done is not possible. So I think it is some kind of mix.
Tariq Ramadan
It is and at the same time it is not because the whole understanding is different. What we see now with many of the things done by Muslims, especially in ethics, is that we listen to the West and we try to respond by taking
and not presenting. My point is that we have a contribution to make. When
we say wisdom is the believer’s stray camel that he is always searching for
(al-ḥikmah dāllat al-mu’min), wherever he finds it, it becomes his, we are
listening and we are taking, but now we have something to give. So we
build from within and not with the obsession to respond, which is completely different. This does not mean that we are not listening. We are listening, but it is dangerous for us to simply say that we have the same
common principles given that the sources of the two philosophies are
completely different. So it is wrong for us to keep on responding. We must
listen and respond, but our response is not a response to their questions.
It is a response to our questions. It is completely different.
Jasser Auda
If I may add something with regards to the philosophy of the Center, we
differentiate between apologetic responses and transformational responses. We do not want to be apologetics or take what others have done
and then say that we have the same thing. Rather, if we try to introduce
something, then we learn from the essence of the others’ philosophies and
try to transform reality by introducing new ideas.
Ali Al-Qaradaghi
In regards to responding, the Noble Qur’an teaches us about two key matters. Firstly, it calls everyone to “…a word that is equitable between us
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Script of Oral Discussions (Day 3, Session 3) 355
and you…” (Qur’an 3:64) or in other words to the shared constants or
unchanging principles. There are indeed many shared things among all of
humanity, especially in medical ethics. The second thing that the Qur’an
asks from us is to rise above. In the verse, “Say, ‘O People of the Scripture,
come [ta‘ālaw] to a word that is equitable between us and you…’”
(Qur’an 3:64), our scholars interpreted “come” [ta‘ālaw] to mean “rise
above” [the verb ta‘ālaw can have different meanings depending on the
context]. In other words, we should rise to a high level so that we accept
from each other and agree with each other on the basic constants.
As Dr. Ramadan said, now we need two things. The first one is to look
for the shared constants or seek the shared well-being of all people. The
second thing is to rise to a high level in such a way that we do not have
partisanship or discrimination.
Mohammed Ghaly
Allow me to summarize the second point so we may move to the third
and last point. It is clear that the Islamic conception of formulating biomedical ethics revolves around the higher objectives of Sharia and alongside them the rules, ethics, rulings, and so on. I think this conception can
assimilate the four-principle approach as well, perhaps adding to or taking away from it some things. In any case, it is clear that we will be using
this conception that is based on the higher objectives.
The third and last point concerns what is next? Sheikh Al-Qaradaghi
suggested having another meeting or workshop to further detail the matters we discussed and agree on how to phrase them. I would like to ask
you if there are any issues or themes that should be on the agenda or if you
have any other recommendations or suggestions regarding next steps.
Ali Al-Qaradaghi
I think now the vision is clear and our task has been narrowed down and
specified more precisely. Biomedical ethics have been discussed and studied
thoroughly, and there is plenty of great literature on the subject. Our job
now is to connect the general principles of biomedical ethics that we have
agreed upon to the higher objectives of Sharia. This is one, unified mission. Our goal is to produce a well-organized document that will of course
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require explanation, detailing, and thereafter linking the contents of the
document to the fundamentals [of Islam] (ta’sīl). For this, I think we need
more individuals on board. We need more physicians, Sharia scholars, and
scholars of the higher objectives of Sharia.
Mohammed Ali Al-Bar
I am looking forward in the next meeting or workshop to having more of
our brothers and sisters from the West or who represent Western philosophy.
Dr. Bredenoord’s and Dr. Beauchamp’s contributions were incredibly
informative and enriched the discussions. I am convinced that now we
better understand one another. Dr. Beauchamp has heard criticism or
reviews from the United States and from Europe; this may have been the
first time Dr. Beauchamp also listened to reviews from and discussed with
people from Islamic world. We also need to listen to experts of bioethics
from the United States, Europe, and elsewhere who have perspectives
other than the ones we have heard. Having different perspectives in this
field leads to a broader outlook on biomedical ethics and a greater understanding of various topics.
Annelien Bredenoord
I certainly agree with the previous remarks. I think you can see it through
in two steps. The first step would be a symposium or a conference in
which the principles of Islamic biomedical ethics are formulated and discussed. I would suggest that you already have a document to discuss so
that it does not remain abstract but you really have a charter or guidelines
or whatever you usually produce. That would be a first kind of meeting
during which you together lay things down conceptually. Then in a second
meeting you could put these Islamic biomedical ethical principles into
practice to see when you start to specify this whether it results in conflicts,
whether it is coherent, and whether it needs adjustments. Then I think you
should invite many practitioners just to discuss this with them.
You can make a document using the case-based approach. You either
take one case and you give comments from different approaches, or you
take different cases and you all comment from the same approach. We have
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Script of Oral Discussions (Day 3, Session 3) 357
a lot of case-based medical ethics textbooks, and it may be useful to see
the similarities and differences.
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Mohammed Ghaly
Dr. Bredenoord has previously suggested that when the document is produced, physicians should be invited to discuss the cases of ethical dilemmas they have faced. She said that when you do this, sometimes you end
up prioritizing one principle and de-prioritizing another because the
purpose of these principles is their application. This is similar to what we
might call medical fatwas or medical unprecedented questions/dilemmas
(nawāzil tibbīyah). She also suggested that after we agree on the principles and finalize the document, we present it at one of the bioethics
conferences.
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Script of Concluding
Discussions: Part One
(Day 2: Session 1 and Session 2)
Tariq Ramadan
Our primary purpose here at the research Center for Islamic Legislation
and Ethics is to address Muslims and Muslim societies, not to address
the West. The West has arrived at principles of biomedical ethics, and we
as Muslims living in Muslim countries are in need of a set of universal
biomedical ethics produced from an Islamic framework. This is helpful in
understanding our goals during this seminar.
Jasser Auda
I agree with Dr. Ramadan and would add that we are in need of this kind
of independent reasoning (ijtihād) in Islamic thought and in the Muslim
world. Through their research, our researchers here at the Center have
become deeply aware that there is a need for principles that address the
issues surrounding biomedical ethics within Islamic thought because
these issues are linked to policy and public interests. We do not deny that
Islamic fiqh academies have done a great job especially in matters of
medicine. Nonetheless, what we need now is not to import policies from
other countries whose nature differs from that of Muslim societies in some
359
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regards. Rather, we want to add to this discipline and benefit from the
wisdom and insights of others so that we may arrive at Islamic values that
address policies in Muslim countries in the issues of medicine. This is our
goal today.
Mohammed Ali Al-Bar
The issues we have been discussing so far present constant dilemmas for
physicians nowadays. Of course the culture of physicians is Western in
nature, as medical schools in the Muslim world rely upon the same curricula and philosophies as Western medical schools. However, there is a
shift as many [Muslim] doctors are becoming aware of differences in
ethical and Islamic legal considerations. Islamic fiqh academies have discussed many issues of biomedical ethics, including abortion and organ
transplants, both of which are considered potentially ethically problematic. All these attempts have intended to arrive at a system that Muslim
doctors could rely on and benefit from. It would be a very effective additional step for Islamic fiqh academies to distribute their research studies
and fatwas on medical ethics to doctors in the Muslim world.
We tend to adopt Western culture in its entirety and simply give its
ideas and notions Islamic names. People do so because they find — and
accurately so — that notions of autonomy, beneficence, nonmaleficence,
and justice are present in Islam as important principles as well. After all,
they are notions common to all of humanity. However, many of our colleagues end up adopting these ideas emerging from the West without any
modifications or amendments.
Others are critical of this trend of taking Western ideas without
amendment. Dr. Abdulaziz Sachedina from the United States wrote a book
that put forth a good critique of the subject in which he argued that Islam
is different from Western culture in many aspects. He himself is an
American Muslim living in the West. In my opinion, his book presented a
balanced approach and, although I differ with him on certain details, I am
in general agreement with his perspective. He basically stated that we
need an Islamic legal foundation for these ethical issues.
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Script of Concluding Discussions: Part One 361
I believe that a person’s sources for morality are human natural
disposition (fitrah), intellect, and religion. Human natural disposition is a
topic Al-Ghazali and many other Islamic philosophers have touched
upon. Ethical values are present in the human being’s natural disposition,
as the Qur’an indicates. God says, “…[Adhere to] the fitrah of Allah upon
which He has created [all] people. No change should there be in the creation of Allah. That is the correct religion…” (Qur’an 30:30).
Ahmed Raissouni
The phrase, “that is the correct religion,” indicates that this natural disposition was importantly reemphasized in religion and that there is a link
between the natural disposition and religion.
Mohammed Ali Al-Bar
Yes, that is an important point.
The second source of morality is the intellect (‘aql), to which Islam
and the Qur’an pay a great deal of attention. Islam focuses on the fact that
one cannot arrive at the truth without using reason and that faith or
belief emerges through reason. We find many instances of verses in the
Qur’an that ask, “Then will you not reason?” or “Then will you not see?”
or “Then will you not give thought?”, to mention few. The intellect is
fundamental to arriving at the truth, whether it is ethical truth, truths about
the universe, or religious truth.
Both human natural disposition and the intellect can be inhibited or
distorted by a person’s whims and desires. God says, “…Pharaoh said,
‘I do not show you except what I see, and I do not guide you except to the
way of right conduct’” (Qur’an 40:29), though Pharaoh was one of the
most corrupt tyrants in history. Arrogance is the most significant example
of human whims that distort sound intellect, and it is at the core of immorality. Arrogance is what caused Satan (Iblīs) to be expelled from Paradise:
“[Satan] said, ‘I am better than him [Adam]’” (Qur’an 7:12). This is why
Islam focuses on purification of the soul, saving it from the shackles of
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arrogance, and directing it towards humility, which are essential concepts
in Islamic ethics in general.
The third source of morality is religion (dīn), which provides needed
direction and guidance since any two people’s intellects will inevitably
differ on some details of what is right and wrong. Of course, there are still
many points of agreement: honesty is deemed good and dishonesty is
deemed bad by everyone and in all religions, for example. However, there
are some behaviors that all religions used to prohibit in the past but that
are widely accepted by, and practiced in, societies nowadays. In other
words, there is a shift in ideas, concepts, and behaviors. So my point is,
because of this shift, we need an established, unchanging reference, and
authority. That is religion.
In essence, there has always been one religion for us, Islam. I do not
mean by that the Islam that we belong to. Rather, I mean the state of submission (islām) in which all human begins should submit to one God.
Despite the different prophets that have been sent, they all basically
preached one message, which is the oneness of God. Prophet Muhammad
(PBUH) emphasized that all the prophets — including Abraham, Moses,
and Jesus, peace be upon them all — are messengers of the same God.
Therefore, we need to distinguish between what is pure religion —
namely, that which was revealed to mankind at different stages of their
history — and the deviations that impacted these religions at the hands of
human beings. For example, in the West now there exist two important
philosophies, one of which is utilitarianism that can be traced back to
Greek history but was more recently developed by Thomas Hobbes and
other philosophers, including Jeremy Bentham. According to Bentham’s
description of this philosophy, if arresting and torturing a group of children
belonging to our enemy will make our enemy surrender to us, then there is
no ethical problem with this. Similarly, if permitting usury is in the interest
of a group of people, then it is also permitted.
As an example, a study showed that if a person smokes 20 cigarettes
a day for 30–40 years he would lose about 5–7 years of his life. Rothmans
[Rothmans, Benson, & Hedges], the cigarette company, conducted a
research study in Czechoslovakia. The study stated that people who died
at the age of 70 rather than at the age of 65 would have spent those extra
years retired, and the state would be required to support them financially.
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Script of Concluding Discussions: Part One 363
They argued that if more people died at the age of 65, the state would save
a lot of money since it would no longer need to support those who continued living. Hence, they claimed that smoking is important because it saves
the state money and is beneficial for hospitals, insurance companies, and
other similar organizations. This is a very clear example of the utilitarian
philosophy, which still affects us today.
The second philosophy, that of Immanuel Kant, developed what we call
“deontology” or the “philosophy of duty.” He did not recognize doing
actions to gain God’s acceptance and pleasure. He argued that actions
should emerge exclusively from a sense of duty. In other words, if a person
acts in order for society or God to reward him, Kant considered his act
to be unethical. Moreover, Kant believed unconditionally that truth is a
virtue and lying is a vice, so much so that even if it led to the killing of an
innocent person, one should not lie. For example, at the time of Nazi
Germany many Jewish people escaped to Morocco from the oppression in
Europe. When the Nazis arrived in Morocco they used to inspect houses,
searching for Jewish people. As a result, the Muslim families there would
hide their Jewish neighbors despite knowing that the penalty for this was
death. When the Nazis would ask a Muslim family where their Jewish
neighbor was, they used to lie since in Islam this would not be considered
sinful. Although telling a lie is not virtuous, saving the life of an innocent
human being is more important and in such a case one cannot claim the duty
to tell the truth is an excuse for surrendering a Jewish neighbor to the Nazis.
Kant also regarded keeping promises as essential. If, for instance,
I told my children that we would go on a picnic on a certain day and on
that day their mother fell ill, I would have a dilemma. One duty would be
to keep my promise to my children and take them on a picnic, and the
other duty would be to their mother, to care for her when she falls ill.
According to Kant, given that you promised your children to take them on
a picnic, you should forget about anything else. Is this really logical? In
my opinion, this kind of thinking lacks balance. Needless to say, being
truthful and keeping promises are undoubtedly important traits. However,
ultimately, it should be a question of balancing between issues depending
on each one’s weight. These situations are often perceived as dilemmas
although they are not actually dilemmas. From my perspective, there is no
dilemma in these cases and the issues are clear.
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It goes without saying that there are other philosophies and many
different schools of thought, but these are the ones I focused on.
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Mohammed Ghaly
As Sheikh Al-Qaradaghi mentioned earlier, putting forth an Islamic alternative in the field of biomedical ethics is considered a new idea in Islamic
thought. There have been many deep, thorough discussions in Islamic
fiqh academies that were mostly focusing on details and specifics like
organ donation, cloning, and abortion. However, there have not been
enough analysis on and discussion about the [broader] ethical principles
in biomedicine.
Sheikh Abu Ghuddah wrote a research paper a while ago entitled
“Sharia-Based Principles for the Profession of Medicine and Medical
Treatment” (Al-mabādi’ al-shar‘īyah lil-tatbīb wal-‘ilāj) in which he
included what he also mentioned in his chapter for this seminar: it is
incumbent on the physician, just like any other professional, to know the
religious rulings related to his or her profession. In his earlier paper, Sheikh
Abu Ghuddah clarified that since it is not reasonable to expect of every
physician to know every detail surrounding religious rulings on medical
practice, physicians are excused from knowing the details. His reconciliation was that physicians should know the [religious] principles related to
medicine and apply them to specific cases using their own understanding
and logic.
I think the first book on the principles of biomedical ethics coming
from Western thought was published in the late 1970’s, and it has now in
2013 reached the seventh edition. It is clear the West has more experience
with biomedical ethical principles than we do in the Muslim world.
Muslim physicians in the Muslim world and elsewhere already deal with
these principles in one way or another, so they are in need of knowing
whether these principles are compatible with Islamic teachings. Of greater
importance is that Islam should have its own say in this field. Perhaps the
theory of the higher objectives of Sharia can provide a solution, as Sheikh
Al-Qaradaghi has suggested, because it starts from an Islamic framework
and at the same time can accommodate what has come before. Sheikh
Raissouni spoke about the fundamental ethics (ummahāt al-akhlāq) as a
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possible entry point for this topic. These starting points are all important,
as they could help us to introduce biomedical ethical principles rooted in
the Islamic tradition.
Ali Al-Qaradaghi
There are general principles — or what we can call fundamental ethics
(ummahāt al-akhlāq) — that we can organize and structure. We want this
organization and the connections therein to be well defined, not vague. In
addition, standards or criteria are critically important. I understand the
concept of standards through the term al-mīzān (scale or balance) in God
Almighty’s verse, “We have already sent Our messengers with clear
evidences and sent down with them the Scripture and the balance
[al-mīzān] that the people may maintain [their affairs] in justice…”
(Qur’an 57:25). God did not say “the Scripture” alone; rather, He said,
“the Scripture and the balance [al-mīzān].” In other words, it is necessary
that with the Scripture comes the balance [al-mīzān] that informs how the
Scripture should be applied.
Another important issue I mentioned in my chapter is linking the
principles of biomedical ethics with the higher objectives of Sharia. If this
initial idea or premise is accepted, then my chapter is open to improvements through feedback from everyone so that we may arrive at a complete and comprehensive product with legal, technical terminology that
can be presented to physicians and others.
Some universities require their medical students to take a core course.
At my university, this course uses the book I coauthored with Dr. Ali
Al-Muhammadi, Jurisprudence of Contemporary Medical Issues (Fiqh
al-qadāyā al-tibbīyah al-mu‘āsirah). It discusses various medical issues,
including cardiopulmonary resuscitation (CPR) devices, DNA profiling,
artificial insemination, and many other issues.
Abdul Sattar Abu Ghuddah
I would like to emphasize what was discussed previously: these principles
apply to all fields, such as politics, education, economics, and so on, as
much as they do to medicine. I hope each of us keeps this point in mind
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and extracts from the principles what he or she finds especially relevant
to the medical field.
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Jasser Auda
I agree with Sheikh Abu Ghuddah. Here at the Faculty of Islamic Studies,
in the Department of Public Policy, we teach a course entitled “The
Higher Objectives of Sharia [as a Basis] for Making Public Policy.” Just
like every example of public policy has a certain philosophical basis, how
can the higher objectives of Sharia form that philosophical basis for
making public policy? The philosophical basis here includes what gets
prioritized, what themes the policy fits under, and other matters.
One element I would like to highlight is inserting and incorporating
the system of Islamic legal maxims or juristic rules into the framework
of the higher objectives of Sharia. In his chapter, Sheikh Al-Qaradaghi
applied the rules of tarjīh (giving preference to one opinion over
another) we normally apply in Islamic law — such as eliminating hardship, avoiding evil, choosing the lesser of the two evils, etc. — to the
traditional set of higher objectives of Sharia. It is an added philosophical
complexity but a necessary one because the philosophies that deal with
such a subject consist of both principles and ways of dealing with complications and contradictions. The inclusion of the juristic rules makes
the picture complete.
Mohammed Ghaly
Incidentally, the four-principle approach is very similar in that it places
four relatively simple principles at high levels and then classifies issues
under these principles. For example, informed consent is classified under
the principle of autonomy. As for the application of these broad principles to specific cases, one can choose to go from the bottom up or from
the top down. Also, as was mentioned before, it is essential for physicians
to have some criteria or standards of measurement when applying ethics
because otherwise decisions will be arbitrary and can be based on
personal whims.
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Annelien Bredenoord
One of the questions was about whether there are universal principles in
bioethics or whether the four principles are universal. If there indeed are
universal principles, how do they relate to religious principles (regardless
of which religion they belong to)? Dr. Al-Bar said that ideas, concepts,
and morals change across societies and over time so we need durable
terms of reference that do not change, or at least do not change as fast as
society might change. Dr. Al-Bar said that for him, that is religion — in
this case, the Islamic religion — but in the end he said that he perceives
all religions to be one and the same.
Mohammed Ali Al-Bar
In their origin.
Annelien Bredenoord
Yes, in their origin. If we want common principles in bioethics, then we
need a common reference point — and I think this is also what Beauchamp
and Childress meant — so the question is: Could this be formulated using
religious language? Since two-thirds of the world is religious and onethird is not, how do we formulate the bioethical principles, given that we
do not share the same moral and religious language? I would be interested
in hearing your comments because I think we need to formulate them in a
language that is acceptable to everybody, and it cannot be one particular
religion because we do not all share it.
Another question I had about the higher objectives of Sharia is how
they relate to the four principles. Can they be included or can we add them
to the four principles? I am curious; maybe they are different, but maybe
we are talking about the same thing.
Tariq Ramadan
I have a question [for Dr. Al-Qaradaghi]. When you mentioned that the
principle of autonomy could be included under the higher objective of
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Sharia related to the preservation of the intellect, were you saying that the
principle of autonomy is a principle or a fundamental (‘aṣl)? Or were you
saying the principle of autonomy can itself be counted as one of the higher
objectives of Sharia?
Ali Al-Qaradaghi
The preservation of the intellect consists of two aspects, positive and
negative obligations. The positive or proactive aspect entails developing
the mind and providing it freedom. Among the necessities of Sharia
(al-darūrīyāt al-shar‘īyah) is that we protect the intellect and its freedom,
creativity, and development. The negative or protective aspect entails
preventing the intellect from harm of any kind.
God says, “And Allah presents an example of two men, one of them
dumb and unable to do a thing, while he is a burden to his guardian.
Wherever he directs him, he brings no good. Is he equal to one who commands justice, while he is on a straight path?” (Qur’an 16:76). God likens
the person who chooses to be entirely dependent on his guardian to a
person in whom there is no good. All scholars agree that independence
and freedom of thought are fundamental to the positive side of the preservation of the intellect.
Tariq Ramadan
My question is about this: Is it a principle or a fundamental (‘aṣl)?
Ali Al-Qaradaghi
Preservation of the intellect is a principle. If we adopt a hierarchical
model, then we could consider it a general principle.
With regard to Dr. Bredenoord’s question about religion, we mean by
“religion” anything a person chooses to follow, whether it is truth or falsehood. Islam protects, defends, and fights for freedom of religion, even if
we consider the particular religion someone chooses to be false. The first
verse to be revealed concerning the protection of [the practice of] religions of all kinds is God’s saying,
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Script of Concluding Discussions: Part One 369
Permission [to fight] has been given to those who are being fought,
because they were wronged. And indeed, Allah is competent to give
them victory. [They are] those who have been evicted from their homes
without right — only because they say, “Our Lord is Allah.” And were
it not that Allah checks the people, some by means of others, there
would have been demolished monasteries, churches, synagogues, and
mosques in which the name of Allah is much mentioned… (Qur’an
22:39–40).
These verses are referring to all [kinds of] places of worship. This is
why we mean by “the higher objective of preservation of religion” that we
are not allowed to demean or belittle any religion. We must respect the
creeds and beliefs of others. My personal estimation and perception of a
person’s religion and the ruling regarding whether it is true or false is
another matter altogether. Therefore, when we use the word “religion,” it
should be understood to mean all religions.
In conclusion, I will say that we embrace the four principles and
include them in our discussions involving the higher objectives of Sharia.
If the four principles are good, useful, acceptable principles that benefit
humanity, then why not make use of them? As we know from a famous
Prophetic narration, wisdom is the believer’s stray camel that he is
always searching for (al-ḥikmah dāllat al-mu’min). Sheikh Al-Tantawi
used to point out that the use of the word dāllah [literally, object or goal
of persistent search or pursuit] implies that Muslims fell short in their
duty to produce this knowledge or wisdom. So when someone else gets
it before, it becomes the Muslims’ dāllah (stray camel), and the least they
can do is take it and benefit from it. So I hope we do indeed include the
four principles in our discussions involving the higher objectives of
Sharia.
Mohammed Ghaly
Throughout this seminar, we have been focusing on two main questions:
(1) What are the Islamic principles in the field of biomedical ethics?
(2) Are the four principles of biomedical ethics from the West universal?
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Before we delve into the details of your comments on these two
questions, I would like to say a few things about the issue of the search
for the principles and fundamentals (uṣūl). Early Islamic scholars wrote
about the fundamentals of ethics (uṣūl al-akhlāq), and Sheikh Raissouni
mentioned them in his chapter when he discussed the fundamentals of
noble ethics (ummahāt makārim al-akhlāq). The philosopher Ibn
Miskawayh identified four items that he considered to be the fundamentals of ethics. They are wisdom, chastity, courage, and justice. This classification was the result of intercultural interaction with Greek philosophers,
who studied the same issue.
Among the philosophers who mentioned these ethics was Socrates,
who said that ethics depends on knowing the good and the evil of acts and
that these four are the fundamental noble ethics. Muslim scholars, including Al-Ghazali and Ibn Miskawayh, expanded and elaborated upon these
four principles by developing an Islamic foundation for them. They asked
a question of utmost importance, and we asked Dr. Beauchamp the same
question but he did not give a definite answer. The question was about the
mechanisms through which these four principles were arrived at and on
what philosophical reasoning or basis they were chosen.
When Islamic scholars took these four principles, they established
mechanisms of interpretation. They said the human possesses three main
powers: the first is the power of comprehension, perception, cognition,
and understanding things; the second is the power to achieve what is
good and beneficial to oneself; and the third is to obstruct that which
is harmful and could include the power of anger, which is sometimes
needed to obstruct harm. They said the first, power of comprehension,
brings about knowledge or wisdom; the second brings about chastity; the
third brings about courage; and balancing the three leads to justice, the
fourth principle.
So they did establish philosophical reasoning for these principles.
However, they also said that these four principles are not enough because
they only have to do with a person’s dealings with other creatures. There
should be a fifth principle, servitude [to the Creator] (‘ubūdīyah) that
will govern man’s relationship with his Creator, God. This is a historical
example of the search for the principles and fundamentals of ethics. It
involved intercultural interaction between the Islamic philosophy and
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Script of Concluding Discussions: Part One 371
Greek philosophy. We should look at how Muslims dealt with Greek
philosophy when they encountered it: they adopted some of it, changed
some of it, and added to it. They also provided the basis or the mechanisms through which these four (or later, five) principles were arrived at.
The parallels between then and now are clear. Our situation today is that
there are four principles that are widespread and have reached Muslim
doctors present in the Muslim world and elsewhere. It is incumbent that
Islam interacts with them.
The first main question that we have been busy with during this
seminar reads: what are the Islamic principles in the field of biomedical
ethics? In addition to addressing this question, we also need to detail the
mechanisms through which we will find or derive these principles. This is
because, as Sheikh Raissouni mentioned in his chapter, the ethical values
in Islam are numerous, and they are divided, subdivided, and branched.
We could count hundreds or thousands, and it is unrealistic to expect a
doctor to know them all. Thus, doctors need broad principles and fundamentals to make it easy for them. What are the mechanisms in our Islamic
tradition that can help us formulate these principles?
Sheikh Raissouni suggested searching for the fundamental ethics as a
mechanism for formulating these principles. He reviewed the work of
Dr. Muhammad Abdullah Diraz, and he ultimately arrived at the two main
ethics; mercy and God-consciousness (taqwá). His mechanism was as
such: he researched the ethics and from the ethics arrived at the fundamental ethics and from the fundamental ethics arrived at what is relevant
to the medical field. He was adamant and determined to find things of
direct relevance to the medical field; he was not concerned with generalities. Sheikh Al-Qaradaghi, on the other hand, found the theory of the
higher objectives of Sharia appropriate for two reasons. First, it has strong
roots in the Islamic tradition and thus does not raise philosophical or religious complications. Second, it can accommodate the four principles and
accept what is acceptable and reject what is not.
To summarize, the first question was: What is the ideal mechanism to
use to arrive at the principles, and then what are these principles as
derived through this mechanism? The second is similar to a question
Al-Ghazali and Ibn Miskawayh dealt with: What is the Islamic contribution with regards to the current Western principles that have become
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widespread globally? It seems that Dr. Al-Bar has something to say about
this particular question.
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Mohammed Ali Al-Bar
The four principles were met with wide acceptance, although it was not
universal acceptance. Even in the United States a group of well-known
scholars had objections to these principles and preferred other ways of
classifying or organizing [biomedical ethics]. Perhaps Dr. Bredenoord can
provide us with more information on the Western perspective regarding
these four principles.
Two of these four principles, namely beneficence and nonmaleficence, can be traced back to the days of Hippocrates. They are included
in all medical codes, including those adopted by Ibn Abi Usaybi‘ah,
Dr. Hassan Hathout, and the Islamic Organization for Medical Sciences.
There is no need for much discussion on beneficence and nonmaleficence, as they have been well established and agreed upon for over
2,000 years.
The recent additions are the principles of justice and autonomy.
Nobody disagrees with justice in principle. However, unlike previous
times, medicine is no longer confined to the doctor–patient relationship.
Today, there are ministries of health and large companies that play important roles in our understanding of medicine. Medicine encompasses
aspects such as general health services in countries where citizens have no
access to medical treatment. It also includes prevention, health polices,
and so on. Changes in our understanding of medicine have necessitated
incorporating notions of justice and equality to ensure everyone is treated
equitably.
Sheikh Abu Ghuddah clarified for us how the Islamic world upheld
justice. The government would make sure that free medical services were
available and accessible, even in prisons and distant villages. Sometimes
the Muslim ruler would even send a team of physicians to a different
nation if he heard of an epidemic happening there.
Now I will move on to the principle of autonomy. In earlier days,
Hippocrates and those following his school of thought encouraged
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Script of Concluding Discussions: Part One 373
physicians to treat their patients as their own children. When a father or
mother deals with their child, they do not always take the child’s opinion;
instead, they do what they know is in their child’s best interest. Some call
this paternalism. A countering philosophy, liberal capitalism, was spreading
in the United States in the 1970s, when Beauchamp and Childress published
their book. This philosophy questioned the notion that an authority such as
a parent or doctor should impose his or her will on others and instead
emphasized personal freedom and autonomy. In medicine, this meant that
the patient’s opinion was deemed more and more important.
The concept of autonomy existed in Islamic law very early on. Over
1,200 years ago, ‘Abd Al-Malik bin Habib stated in his book on Prophetic
medicine that a physician should take two permissions [to practice]: that
of the government [through obtaining licensure] and that of the patient or
the patient’s guardian. Sheikh Al-Qaradaghi referenced the case in which
the Prophet (PBUH) refused medicine forcefully administered to him.
Similar occurrences that happened to others during the Prophet’s (PBUH)
lifetime showed clearly the importance of obtaining a patient’s consent
before treatment. Numerous Muslim jurists — including Ibn Al-Qayyim,
Al-Ghazali, Ahmad, and others — wrote about these issues in detail, often
differing on certain details. So the question of a patient’s autonomy is not
new to Muslims; on the contrary, there is a long history of discussion
about it. However, we differ with the West about the extent of personal
freedom a patient has in making medical requests in some sensitive issues
like sex change and abortion.
Tunisia has now adopted the Western principles concerning abortion,
without limitations or conditions that consider important factors such as
the age of the fetus. A woman can go to a doctor and ask for an abortion
without having any medical reason to do so. Arab countries should place
conditions on aborting a child, such as the presence of medical reasons or
because the pregnancy was the result of incest or rape. Although a doctor
has the right to refuse to abort a woman’s child, he is expected to refer her
to another doctor. He does not have the right to advise a woman that abortion is right or wrong. In doing so, a doctor would have departed from [the
accepted standards in] the medical field. Such a doctor would be considered paternalistic, and paternalism nowadays has become almost like a
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crime! It would not be unusual for such a doctor to be prevented from
practicing or to be penalized in some way.
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Mohammed Ghaly
Dr. Al-Bar said that beneficence and nonmaleficence are undisputed, and
therefore we can consider them to be universal. He mentioned that injustices started happening because of the changes in the medical landscape,
and justice was thus introduced as a principle. Sometimes a principle is
formulated for the purpose of fighting an ill in society. So as we formulate
biomedical ethical principles using the Islamic framework, we should take
into consideration the reality of the Muslim world today. For example, the
West may have the problem of equal access to medical care while the
Muslim world has other problems to overcome, hypothetically speaking.
Physicians are perhaps in a better position to give us examples of problems they see so that our Islamic scholars can tell us which principles to
establish in order to address these problems.
The principle of justice was also introduced because of changes that
made the field of medicine broader than the doctor–patient relationship.
In addition, the liberal political theory inevitably had an effect on the discussions about the patient’s autonomy. However, it seems there remains
some confusion about the distinction between the question of patient
consent and the wider issue of autonomy. Does the issue of consent fall
under autonomy, or is it a synonym of autonomy? We need further explanation of the distinction between informed consent and autonomy and the
relationship between them. In Islam we have no problem with the principle of consent, but we disagree on the extent to which we accept a
patient’s informed consent. According to the Western principle of autonomy, there are almost no limits because if the patient wants and agrees to
a certain procedure the doctor should provide this service given that
financial ability and other necessary resources are available. This has been
a point of contention in laws in various countries.
If Dr. Bredenoord would like, perhaps she can add something in
regards to the relationship between the principle of autonomy and
informed consent. In addition, she may be able to comment on the question of autonomy being limited: Is autonomy limited/restricted only
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Script of Concluding Discussions: Part One 375
because of financial and logistical reasons, or is there also an ethical
dimension to it?
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Annelien Bredenoord
Before I discuss autonomy, what strikes me is that the two principles of
beneficence and nonmaleficence are shared by everyone and are uncontested. I think this is logical given that these two principles date back to
the Hippocratic tradition — the Greek source that we all share — whereas
the other values, autonomy and justice, are relatively new values. Autonomy and justice were only introduced in Western medical ethics in the
1970s, so it is logical that our discussion focuses on these two values. In
addition, within Western bioethics, these are the most contested values.
The debates in Western bioethics are about the fitting in of justice and the
fitting in of autonomy. I think everybody accepts the principles but differs
on how to interpret them.
It goes without saying that everybody accepts the formal principle of
justice. We agree that we should have procedures for justice such as
equals must be treated equally and unequals must be treated unequally for
as far as they are unequal. In other words, the formal part we all agree on.
The material part of justice, the substantive accounts, is where we have
huge political debates. This is because we have to decide on what justifies
making a distinction between people. We have liberal theories, egalitarian
theories, the Amartya Sen Capability Approach, and so on. So yes, we
accept the formal principle of justice but then we do not go beyond that.
Even within the egalitarian theory, for example, it may be illustrative to
read the report by the World Health Organization. They issued an ethical
report on what happens in the case of a pandemic, how vaccinations
should be distributed, and how to allocate who gets what in situations
where the vaccination [supply] is insufficient. They make a type of egalitarian account, where they provide the vaccination to adolescents, young
people, and health workers while the elderly and a few other groups do
not receive it. Basically, they make a decision and they have a good ethical base for it. This is a good example of how they perceive justice.
In regards to autonomy, I think it is very important to make a distinction between positive obligations and negative obligations, or positive
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autonomy and negative autonomy. Once again, everybody accepts
negative autonomy, which refers to the right to non-interference. I will
give an example from reproduction. In the European Charter of Human
Rights we have negative reproductive autonomy. This means that a woman
cannot be forcefully sterilized and cannot be forced to have an abortion.
That is the right to be left alone and is quite uncontroversial universally.
On the other hand, there is the positive autonomy right, which refers
to the right to ask for something. For example, there is the right to start a
family and ask for in vitro fertilization (IVF) or assisted reproduction and,
in fact, there is debate about this topic. It is not true that autonomy is limitless. In my opinion, negative autonomy is limitless whereas positive
autonomy has many limits. These limits can be associated with issues of
justice, harm to others, etc. So autonomy is a very thick concept, and we
should avoid saying “autonomy” without making the distinction between
positive and negative whenever it is discussed. This similarly applies to
the topic of assisted death. If a patient asks a physician for euthanasia, this
raises the question of positive autonomy. For example, in the Netherlands
it is not obligatory for a physician to help somebody with dying. It is
something you grant to a patient, but it is not something that you have to
do. This highlights that there are several examples where we can distinguish between positive and negative rights.
Moving on to the question about the relationship between autonomy
and informed consent, I think informed consent could be seen as an
operationalization of autonomy. The principle of respect for autonomy
requires you to provide information, which is the informed part, and also
requires you to ask for consent — or informed refusal of treatment. In
other words, autonomy is the foundation or the cornerstone, and informed
consent is one of the practical operationalizations. In research ethics,
informed consent was particularly emphasized in the Nuremberg Code
after the Second World War. Informed consent had two main functions in
this international code. The first function was respect for autonomy and
the second had a protective rationale. If you as a physician want to conduct research, you have to ask if the person allows you to perform medical
experiments [on him or her]. Such a person is better protected than when
the physician does not have to ask. So the basis of informed consent is
both protection and autonomy.
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Script of Concluding Discussions: Part One 377
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Hassan Chamsi-Pasha
I would like to add several remarks to the points raised by Dr. Al-Bar.
Medicine has become a sort of trade and the doctor is viewed as a kind of
service provider. Patients are perceived as clients. This can be found in
many countries across the world and is also true of the companies that
regulate hospitals like ISO and others. This concept is inimical to the field
of medicine and to the doctor–patient relationship. Doctors as service
providers compete for the clients or customers, and the result is a commercial mentality.
The second point I would like to address is the mistakes committed
by doctors. We read in newspapers everyday about doctors and hospitals
without any ethics, and a few weeks ago a hospital in Saudi Arabia was
made to close for 2 months due to a medical mistake that had taken place.
Any patient in many of the Gulf Cooperation Council (GCC) countries
can place a complaint against a doctor after the doctor has treated him or
her. The doctor’s passport gets confiscated for 2, 3, or even 5 years until
the court proceedings are completed. In the end, if the judge reaches a
final decision that the doctor was not at fault, the doctor does not receive
any compensation for the adversity he has gone through. This is a reality
I have witnessed myself. Any person can write a letter — one letter is all
that is needed — to place a complaint against the doctor. In the end it
is the doctor’s dignity and reputation that receive a great deal of harm.
These processes must be regulated, as it is unacceptable for these types of
things to take place in the medical field.
I would also like to make a comment about drug companies. These
companies exert a great deal of pressure on doctors. Previously we were
discussing statins, which help reduce cholesterol levels in the blood.
There are several drugs of this type produced by different companies that
vary in their strength and effectiveness but have comparable prices. The
drug companies play an active role in directing the doctor to prescribe one
drug instead of another. There needs to be a focus on the ethical aspect in
this matter. How can we direct the doctor to do what is ethical in such
situations?
This also applies to blood pressure medication. There are five main
groups of such medication, and in each group there are several different
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medicines from which, according to international medical guidelines, a
physician is given the liberty to choose. However, not all medicines have
the same strength and effectiveness, and they have different side effects
and associated complications. Hence, controls must be put in place to
regulate a doctor’s choice of medicine, especially as it relates to the pressure exerted on him or her by these companies. Of course, a doctor cannot
be directly accused of doing anything wrong by choosing one medicine
and not another. However, he or she could hypothetically choose a medicine even if it is not in the interest and benefit of the patient.
The final point I would like to refer to is the importance of focusing on
preventative medicine and health education. It is one of the most important
aspects of medicine, and it is not at all costly. God stated, “…and eat and
drink, but be not excessive…” (Qur’an 7:31). The fields of health and nutrition are summarized in part of a Qur’anic verse. Nowadays, international
guidelines encourage trying to lose weight, reducing the amount of food we
consume, practicing sports, etc. Unfortunately, doctors nowadays do not
spend enough time talking to their patients about taking preventative measures. We establish many health centers and cardiovascular clinics but are
negligent about the preventative side of medicine.
Ahmed Raissouni
Dr. Bredenoord posed a question to Sheikh Al-Qaradaghi on how we can
rely on the higher objectives of Sharia without imposing one religion,
namely Islam. I would like to clarify that the higher objectives of Sharia,
especially the five necessities identified by Sheikh Al-Qaradaghi and
other religious scholars, are likely common to all world religions and
religioethical frameworks, not just Islam. We should call them “the higher
objectives of Sharias,” by using “Sharia” in the plural form.
I have not consulted all other religions’ views on the matter, so I cannot guarantee that the five necessities (the preservation of religion, life,
offspring, the intellect, and wealth) are agreed upon by all religions.
However, my point is that we can in principle identify what the higher
objectives of other religions are, add them to the ones in Islam, have
all higher objectives “interact” with one another, and choose from the
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Script of Concluding Discussions: Part One 379
mixture what we can call “the higher objectives of religions.” As
mentioned earlier, two-thirds of the world’s population is religious, so it
would be beneficial to identify the higher objectives that are common
across all religions and adopt them or build upon them as needed.
Dr. Al-Bar’s comments on autonomy as they relate to matters such as
sex change, abortion, and euthanasia compelled me to consider some questions. What is medicine? What purposes does it serve? As Dr. Chamsi-Pasha
asked, is medicine a business or trade? A physician has medical skills and
can use those skills as he or she wishes. Will the physician use them to serve
whoever can pay, regardless of what the payer asks for, as if they are
engaged in business? If this indeed were medicine, then euthanasia would
be accepted; any physician could easily put an end to suffering through
injections or medications. A physician could change a person’s gender for
$10,000 or help a woman have an abortion, even when she is 8-months
pregnant since these are skills the physician has similar to any other skill
possessed by others. Similarly, people who know how to make a bomb
could make bombs and sell them to other people simply because they possess the know-how.
What is the definition of medicine? Since many ethical issues depend
on it, we need to know whether there is a universal, agreed-upon definition
of medicine and whether there is universal agreement about its purposes. Is
medicine a set of skills learned by the physician that he has the right to make
money from as he wishes? Or is it a profession? The layman definition is
that the physician treats illness. So whatever is not an illness does not
require intervention by the physician. If a woman is due to give birth in a
few weeks and the pregnancy is not harming her, then where is the illness
that requires medical intervention? I would like to ask the physicians here
especially: Is there a specific definition of medicine, its role, and its boundaries? Knowing its boundaries is especially important because many
[ethical] violations — whether in business, religion, or any other field —
transpire because of stepping outside the boundaries of the field.
Regarding the formulation of principles, I reiterate that we should
deal with issues most relevant to medicine and medical practice and
applicable to all times and places. In my opinion, we must include as the
preface to the universal principles of biomedical ethics the sanctity of
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human life and its equal right to be protected. The principle of protecting
human life may solve many challenges we come across. When a physician deals with a patient, he is dealing with a human soul, which is sanctified in all religions. God says, “Because of that, We decreed upon the
Children of Israel that whoever kills a soul unless for a soul or for corruption [done] in the land — it is as if he had slain mankind entirely.
And whoever saves one — it is as if he had saved mankind entirely…”
(Qur’an 5:32). God expresses that this rule was initially directed at the
Jews, while He is addressing Muslims. This indicates that the rule applies
across time.
A physician should remember that human beings enjoy a sanctity that
must be preserved, and we are all equal as far as this trait is concerned.
Whether rich, poor, man, woman, young, old, princes, ministers, Muslims,
non-Muslims, atheists, etc. we are to deal with all human souls equally
with respect to their right to be protected. God says, “And We have
certainly honored the children of Adam…” (Qur’an 17:70). In this verse
God mentions the children of Adam [collectively]; being Muslim or
non-Muslim is a separate matter.
The second point I would like to address is human dignity. Unfortunately
in some hospitals, patients are not always treated with dignity during
operations, treatments, and examinations. The physician should remember
he is not dealing with merely a physical body. This body enjoys Godgiven sanctity and dignity. Thus, the sanctity of human life and respect for
human dignity are two principles that could be considered as additions to
the principles.
As for God-consciousness, which was discussed at length previously,
its particularities are specific to each religion yet the concept exists in all
religions. While we could try to bring out the shared notions, it may actually be that each religion has its own distinctive definition. In addition,
I mentioned the concept of mercy earlier as being crucial given the nature
of the medical profession and the delicacy of patients’ privacy and confidentiality. If governments, ministries of health, pharmaceutical companies, and other involved entities are not merciful, they may easily find
themselves operating materialistically and inhumanely and taking advantage of patients. Mercy is essential in all fields but is particularly pertinent
to the medical profession.
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Abdul Sattar Abu Ghuddah
I would like to reiterate that mercy killing is banned in Islam — not only
for human begins but also for animals. Historically, when a horse was
deemed incapable of moving, he was killed. However, in Islamic history
we find an endowment that was created for disabled horses to be taken to
a grazing land so they could eat and drink until they [naturally] died. In
his book Some Glorious Aspects of Our Civilization (Min rawā’i‘
hadāratina), Dr. Mustafa Al-Siba‘i described an endowment created for
mutilated or disabled horses. Muslims strove to protect and preserve the
sanctity of both human and animal life.
I do not know if this is the case for the four principles, but for the
higher objectives of Sharia, all of them should be adopted together. We
cannot activate some higher objectives and exclude others. Also, the higher
objectives should serve to restrict one another. In other words, we cannot
take the preservation of life and ignore the preservation of the intellect or
the preservation of wealth. They have to be adopted together because they
complement one another.
Also, the higher objectives of Sharia have their own hierarchy: the
preservation of religion, then life, and so on, and this is significant. For
example, it might be said that capital punishment as a result of equitable
punishment (qisās) [for homicide] or as a result of highway robbery
(hirābah or qāti‘ al-tarīq) is counter to the preservation of life. However,
we say that the preservation of religion takes precedence over the preservation of life.
Mohammed Ghaly
Do scholars agree upon the ordering of the higher objectives of Sharia, or
are there differences of opinion about it?
Ahmed Raissouni
Differences of opinion exist only about the preservation of offspring and
the preservation of the intellect. Al-Ghazali and his followers ranked the
preservation of the intellect higher than the preservation of offspring.
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However, Al-Amidi and his followers ranked the preservation of offspring
above the preservation of the intellect because they considered the intellect to be part of both offspring and life. Scholars agreed that the preservation of religion comes first, the preservation of life second, and the
preservation of wealth takes the fifth position. They only disagreed about
the order of the third and fourth, which are the preservation of the intellect
and offspring, but this is merely a theoretical debate and does not have
practical consequences.
Jasser Auda
Al-Amidi disagreed with the very idea of ordering the higher objectives
of Sharia. He cited the Prophetic narration stating that whoever is killed
defending his wealth is considered a martyr and whoever is killed defending his honor (‘ird) is considered a martyr.1 The order mentioned in this
narration differs from what is mentioned elsewhere. Thus, there are differing opinions as to whether the objectives can be ordered in principle
and, if they can be ordered, how.
As for the chapter of Sheikh Al-Qaradaghi, I believe we have to
address the kind of mechanism adopted there. The mechanism utilized in
Western philosophy is very different from the mechanism we adopt in
Islamic Sharia as far as higher objectives are concerned. The mechanism
in Western philosophy goes back to Greek philosophy. The philosopher
would look at a number of virtues and try to put them in order. He would
talk about the core virtues first and then about the virtues that branched
out of the core virtues. So the core virtues became what can be considered
the principles or the main virtues.
In Islam, when we approach the higher objectives of Sharia, the
employed mechanism is istiqrā’, which involves induction based on consulting the Qur’an or scriptural texts rather than depending on a self-made
list of virtues as the Greeks did. This method depends on the scriptural
texts, the components or details of the religious texts, and the comprehensive ideas included in these texts. When discussing the higher objectives,
Al-Shatibi started his discussion with the method of istiqrā’ and made it
1
Al-Bukhari, Al-Madhalim wal-ghadab (no. 2470), on the authority of Abdullah bin ‘Amr.
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Script of Concluding Discussions: Part One 383
an integral part of his theory. From his perspective, reviewing related
religious texts would enable us to extract the main objectives, which of
course is different from the methods used by Greek philosophers.
Nevertheless, the search for higher objectives is something common
to both Muslims and non-Muslims. Nowadays, those who examine the
higher objectives and purposes in the other religions do so under the name
“studies of systematic theology.” They examine the Torah and the Bible
in order to see what higher objectives they can infer from the legal laws
they take from the Scripture. This systematic method leads to a system of
higher objectives similar to what we have in Islam, with the exception of
the preservation of religion. In my research on the studies conducted by
systematic theologians I have not found any mention of the preservation
of religion. There is, however, reference to the preservation of dignity and
reason as well as progeny when talking about family. We could perhaps
use this system as a means through which we can create a common background or common methodology.
Hassan Chamsi-Pasha
I have a brief comment about the preservation of honor. On a daily basis,
patients in hospitals are left undressed after they have been anesthetized.
Unfortunately, some physicians are lax in their concern for preserving the
honor or dignity of their patients in this regard. Because this is a daily
problem in many hospitals in the Arab and Muslim world, I think the
higher objective regarding preservation of honor should be given particular attention.
Abdul Sattar Abu Ghuddah
The preservation of dignity differs from the issue of nakedness. The preservation of dignity entails prohibiting people from promoting ungrounded
accusations against others of evil acts such as slander or fornication. As
for ensuring that the body is covered, Muslim jurists have classified it
among the supplementary commandments (tahsīnīyāt), not from the
necessities (darūrīyāt) or needs (hājīyāt) because of the situations that
necessitate undressing such as for medical purposes.
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Hassan Chamsi-Pasha
However, it is no doubt that deliberately keeping a patient’s body uncovered is counter to the preservation of dignity. The fact that anyone standing in an operation room can see a patient’s body uncovered and later
watch the patient leave the operation room does fall under the topic of the
preservation of the dignity of the patient.
Annelien Bredenoord
It may be interesting to know we had an ongoing discussion about what
dignity is. In the end, many scholars equated dignity with autonomy. The
intrinsic worth of human beings is now quite often equated with autonomy, so now we use the word “autonomy” for dignity.
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Script of Concluding
Discussions: Part Two
(Day 3: Session 1 and Session 2)
Mohammed Ghaly
We have been discussing the four-principle theory, which began in the
West and eventually spread to the rest of the world. We will start this
round of discussions with Dr. Bredenoord presenting a basic idea of the
theory. If possible, she will also provide us with specific terms used in
the English language and explain how we can classify them into main
principles and subcategories so that we have a better understanding of
some aspects about this theory that we have been struggling with so far.
After Dr. Bredenoord’s presentation, I will open the floor for discussion
and commentary regarding the universal nature of these principles
and whether they are compatible with Islam. This is the first point of
discussion.
The second point is the Islamic contribution. Which general principles
or fundamentals (or whatever term(s) we end up using) with relevance to
biomedical ethics can we derive from the Islamic tradition? We have the
three chapters presented respectively by Sheikh Raissouni, Sheikh Abu
Ghuddah, and Sheikh Al-Qaradaghi that made distinctive suggestions in
this regard.
385
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Sheikh Raissouni suggested what we could call the virtue-based
approach, which aims to search for the fundamental ethics (ummahāt
al-akhlāq). We have a large collection of ethics in Islam, so how can we
select from this collection the fundamental ethics? Also, what makes a
particular ethical value or virtue part of the set of fundamental ethics?
Sheikh Raissouni expressed his dissatisfaction with choosing a set of
principles that is equally applied to politics, medicine, and all other fields.
We will discuss this point: Should we take the general principles that are
applicable to all fields — like the higher objectives of Sharia — and apply
them to biomedical ethics? Or should we, from the beginning, choose
principles that are especially relevant and applicable to biomedical ethics?
Sheikh Abu Ghuddah’s suggestion was closer to the idea of the etiquettes of the physician. He mentioned God-consciousness (taqwá) and
mercy in his chapter, and during a previous discussion, he added dignity
(karāmah) and respect for human life. His discourse does not focus much
on the patient but rather pays much consideration to issues surrounding
the physician.
As for Sheikh Al-Qaradaghi, his chapter has to do with the Islamic
perspective on the concept of principles and how it is related to the higher
objectives of Sharia. One important question here is whether the higher
objectives are ordered, especially if they are applied to matters of biomedical ethics.
We also have the idea of ta’sīl [developing a framework rooted in the
Islamic tradition] and tawsīl [communicating this framework to the public], in the words of Sheikh Bin Bayyah. Ta’sīl will be purely Islamic in
nature, but tawsīl will not necessarily be Islamic but rather universal in
nature. This is why I kindly request from our Islamic scholars to discuss
whether an ethical value can be inherently good (tahsīn) or bad (taqbīh).
I hereby invite Dr. Bredenoord to give her presentation.
Annelien Bredenoord
I will try to briefly explain and repeat the main definitions of the four
principles as well as the main problems of interpretation and what has
been misunderstood or misinterpreted in the Western literature. I will then
briefly speak about the process of specification or, in other words, how we
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Script of Concluding Discussions: Part Two 387
apply abstract principles to concrete moral cases and finally will end with
terminology.
One of the things I learned during this seminar is that the principles
of beneficence and nonmaleficence are a part of the centuries-old Hippocratic tradition and that they generate the fewest debates. They are the
most direct and clear. Even in Western discussions, there has not been that
much discussion about beneficence and nonmaleficence. The two novel
principles of autonomy and justice are the most controversial and have
raised the most problems in understanding and interpretation. None of the
principles alone is considered to be enough or sufficient. Rather, they
form a comprehensive and complementary set of principles. I will try to
demonstrate, using some examples from my own research, that if you take
just one principle there will always be a conflict or a problem.
I would like to start with the principle of respect for autonomy. The
concept of autonomy originally stems from the independent Greek citystates, and these Greek city-states were autonomos, meaning they had
self-rule or self-governance. It was in Western philosophy that this concept of autonomy was applied to individuals. It was particularly the
German philosopher Immanuel Kant who applied it to individuals. He
literally said that persons should start to make and set their own rules and
their own roles and govern themselves instead of authority or somebody
else doing it for them. At a minimum level, autonomy is defined as selfrule free from both controlling interferences by others and interferences
or limitations by oneself. The autonomous individual acts freely in
accordance with a self-chosen plan. This is analogous to the way an
independent government manages its own territory and its own policies.
One has diminished autonomy when there are external or internal limitations in decision-making capacity. An example of an external limitation
is when somebody is coerced to make a decision, such as when someone
is put under pressure or is in prison and has to make a decision and is
[thus] exploited. When one does not get full information, he or she cannot make an autonomous decision. An example of an internal limitation
to autonomy is when one has mental illness or when one is seriously
diseased.
I think one of the confusions in the debate on autonomy is that there is
a distinction between a negative and a positive interpretation of autonomy.
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In a negative or thin account, autonomy means “the right to make one’s
own decisions without interference or coercion from others.” This is what
Isaiah Berlin called “freedom from.” I think this is a very important
account of autonomy, but it is not enough. This is where the debate begins.
Some people, perhaps particularly scholars in the United States, emphasized the negative account of autonomy, which is simply the right to make
your own decisions, and that is it. I also emphasized the positive account
of autonomy, which is the ability to take control of one’s life and to live
according to one’s values, plans, and beliefs. This account is more associated with concepts such as self-governance, authenticity, self-expression,
and self-rule. Taken together, you have a thick account of autonomy.
However, acknowledging only the negative account is the reason why
autonomy is often criticized to be superficial, individualistic, and shallow.
I will present a short example. Currently, one of the most important
ethical debates in the medical literature is in genetics research. Due to
novel genetic technology we can now very inexpensively map our human
genome. The DNA of one person costs about $1,500 [to map], and you
can do it in a couple of days. It is increasingly used in clinical medicine,
in research, and in cardiology and it is also being introduced in oncology.
One of the moral questions is whether we have a moral obligation to
inform people about their genetic constitution. Should we provide them
feedback about their DNA? Over the last 2 years only, hundreds of papers
have been written about this topic.
If you apply the principles to this debate, you can use the principle of
autonomy. If we consider the negative account of autonomy, you can say
that it is sufficient to just inform a research participant or patient that they
are part of [a] genetic sequencing [project] but that they will not receive
feedback on their genetic information. Just giving them the information
and letting them decide is enough. However, if you take the positive
account of autonomy, you can say that simply taking somebody’s informed
consent is insufficient because having information about your genetic
constitution may help you think about a life plan, give you existential
meaning, and help you take control over your life — control over your
diseases and your life plans. Hence, from a positive account you would
say, yes, you have to inform people about their genetic constitution. That
is basically the interpretation of these two concepts, and together we call
them autonomy.
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Script of Concluding Discussions: Part Two 389
Now we will move on to the second principle, which is nonmaleficence. I think this principle is the most straightforward with the least discussion. It can be translated as, “First do not harm,” and it actually requires
the avoidance of causing harm to others. Harm can be defined as the setting
back of interests of an individual. If we refer back to the discussion on
informing patients about their genetic constitution, then you can specify
this in two directions. You can say that disclosing genetics information
is quite often harmful because people will get worried. It is about risk
information, about probabilities rather than certainties. It has negative consequences for obtaining insurance and healthcare, and it also has psychological consequences. Given the fact that we should not do harm, we should
not inform people about their DNA. This would be a line of reasoning using
this principle.
I do not think there needs to be further discussion about nonmaleficence, so we can proceed to the third principle of beneficence. Actually,
this is a group of principles, and it requires three things. First, it requires
that we prevent harm from occurring. Second, it requires that we remove
harmful conditions that could exist. Third, it requires that we promote the
good of others. I believe beneficence is one of the most well-known principles in medical ethics, but there are two challenges or problems associated with this principle that need continuous consideration.
First, if you use the principle of beneficence without any limits or
restrictions and without balancing it with other principles, then it may lead
to paternalism. A physician could use this principle endlessly to do whatever is good for the patient and could intervene for the sake of the patient
because in his or her opinion it would be good for the patient. As a result,
we need autonomy to counterbalance this principle because if we only
have beneficence then it is only the doctor who is doing good for the
patient. So if we have beneficence we should always have some kind of
autonomy to counterbalance it.
The second challenge associated with this principle is the debate
regarding the scope and limits of beneficence. This is because beneficence
is what we call a “maximizing principle.” If you have the duty to promote
the good of others, which is quite utilitarian, where does it end? Where
does it stop? In principle we can endlessly promote the good of others, but
then we must ask how much effort should be put forth to promote the good
of your patient or your research participant. Are there any limits to it?
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Here one arrives at a philosophical debate about what we can
reasonably ask from other people. So here the physicians’ and also the
researchers’ protective duties are generally quite strong and clear, but if
the physicians’ and researchers’ duties include promoting the best interest
of others, they need demarcation. For example, a demarcation could be
the principle of justice or the principle of autonomy. Here again, if you ask
whether we should inform people about their genetic constitution, then
the principle of beneficence would say yes but only for the genetic information that is clinically relevant and useful to preventing disease or
avoiding deterioration. There are also limits on the efforts the physician
has to exert. I think the challenge for beneficence is in defining the scope
and limits of duty.
The final principle is justice. This is one of the newest principles in
medical ethics. It is also a group of principles. It requires that there be a
fair distribution of benefits, risks, and costs across all parties in a given
society. Justice actually defines the rules for cooperation. However, the
problem with the principle of justice is that it is not an action guide.
It needs filling in by a theory of justice. If we examine Western political
philosophy in the 20th century we find many political philosophers who
tried to find a theory of justice, John Rawls being the most well known
among them. A distinction must be made between formal theories of justice and material theories of justice. A formal theory of justice just defines
the procedure for treating one another fairly. It is often traced back to
Aristotle, who said that a formal procedure of justice is that equals must
be treated equally and unequals must be treated unequally, which is obvious for most people. So the principle is formal because it does not identify
a particular respect in which equals should be treated equally, and it provides no criteria for determining whether two or more individuals are in
fact equal.
The problem therefore is that the principle lacks substance. For example, if we have to treat equals equally, when is it justified to make differences between people? If there is a job vacancy, for instance, and it is
accepted that we should not make distinctions based on race or gender,
what are legitimate reasons for employing one person over another?
In the end, formal justice will not provide an answer to this. We need
substantive criteria. If you have one dialysis machine or one organ and
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Script of Concluding Discussions: Part Two 391
several people who need it, in the end, the formal principle of justice
will not provide an answer as to how these scarce resources should be
distributed. Thus, we need a material theory of justice. We have traditional
theories of justice like utilitarian, libertarian, egalitarian, and communitarian
theories as well as more recent theories of justice such as the capability
approach and many well-being theories. Regarding the example of genetic
testing and providing DNA information to patients, whether justice
requires you to provide those results completely depends on your theory
of justice. In other words, the term “justice” alone is just a starting point.
It is a principle literally, but then it needs interpretation. That was very
briefly regarding the four principles.
The next issue I would like to address is that of specification. In the end,
we have principles that are quite abstract and need to be filled in by theories.
The process of translating the abstract norm into a considered judgment is
what at least Beauchamp called specification. This is a time-consuming
process that requires skills and needs a lot of argumentation. We cannot in
just one hour specify principles or apply abstract principles to specific
cases. I believe the core job of an applied ethicist is to translate principles
to practical cases. It requires professionalism, some kind of craftsmanship,
some sensitivity, and some experience. It involves a subjective scholarly
element. One could say that a specification — a judgment — is justified if
it is consistent with the norms of common morality (meaning if it does
not violate common morality) and if it is internally coherent with the
overall set of relevant and justified beliefs of the party carrying out this
process of specification. So if I concluded in one paper that we should
return genetic results to patients based on such-and-such reason, I cannot
in the following paper conclude the opposite or argue for something that
is internally incoherent with my own work. The same applies to everybody contributing to the process of specification.
As was said during the previous discussion with Dr. Beauchamp,
there are some challenges. First, there is no accepted account on what our
common morality is. What does it mean if an issue has to be consistent
with common morality while we do not agree on common morality? The
second problem is that we do not have a good coherence theory. We have
no good account on what constitutes coherence. These are some challenges for the future.
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Finally, I will discuss terminology. The resources I used in formulating
term definitions are the book authored by Beauchamp and Childress, my
own books, and the Stanford Encyclopedia of Philosophy. Clearly, these
resources collide with each other, so I should include other resources to
get a better overview of all the definitions. For now, I will provide the
headlines of the definitions.
A principle can be defined as “a primary or general moral norm.”
Ideals are also principles or values, but the difference is that an ideal is “a
principle or value that one actively pursues as a goal.” So an ideal is something that is valuable and worth striving for. A virtue can be defined as “a
positive trait or a quality deemed to be morally good.” The opposite of a
virtue is a vice. I think there will be agreement on the definition of this
term. A right or moral right can be defined as “a justified claim.” It can
also be defined as “a legal, social, or ethical principle of freedom or entitlements.” In other words, rights can be defined as “the fundamental normative rules about what is allowed of people or owed to people according
to a certain legal system, social convention, or ethical theory.” A rule can
be defined as a standard or a norm. Here we can see the overlap between
norms and standards. A norm can be defined in many ways. For example,
in statistics a norm is the average. However, in ethics a norm is “a guide
for action and behavior.” Finally, guidelines are “statements through
which to determine the course of action.” So guidelines aim to streamline
processes and to define norms for a certain practice.
Mohammed Ghaly
I hope the four-principle theory is getting clearer to everyone now. There
are some objections about the theory from an Islamic angle; I will mention
some of the ones that have been said before, especially by Dr. Al-Bar, and
then will continue with what Dr. Bredenoord said.
Firstly, these theories did not materialize in vacuum. Rather, they have
a philosophical background and a reality within which they were born. As
Dr. Beauchamp stated in his research, reality is fundamentally changing
in the medical world, and contemporary medical professionals can no
longer use the medical ethics developed on the basis of Hippocratic
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Script of Concluding Discussions: Part Two 393
theories to solve the ethical problems they face. This is why a new theory
had to be developed.
The second point is that while principles such as autonomy, beneficence, nonmaleficence, and justice are undoubtedly in line with the spirit
of Islam, they are based on Western philosophies. If problems of definition occur, then we must refer back to these philosophies to solve them.
The principles are not separate or detached from the Western philosophies
from which they emanated.
The third point is that these principles are general. They are intended
to be general because those who set these principles wanted them to be
universal and wanted their application to be left to the discretion of practitioners. This is both a positive and a negative thing. It is positive in the
sense that it gives Muslims the flexibility to expand or contract certain
elements without rejecting the theory. It is negative in the sense that whoever believes that the matter is in principle Islamic will be taking the
theories [implicit therein]. For example, as Dr. Bredenoord mentioned,
applying the principle of justice necessitates using a theory. So if Islam is
absent, there will be problems during application.
I invite opinions regarding the four principles’ background and application. What do we take from them, and what do we leave when applying
these principles?
Abdullah Bin Bayyah
In my opinion, these principles or concepts or generalities (kullīyāt) —
name them whatever you want — are a combination of some virtues or
ethical notions that are neither Western nor Eastern; rather, they are everywhere and are shared by all humanity. Every human being loves justice
and beneficence and abhors injustice and nonmaleficence. If the West has
directed these virtues towards the medical field, that is good. We believe,
“Indeed, Allah orders justice and good conduct and giving to relatives and
forbids immorality and bad conduct and oppression…” (Qur’an 16:90).
We have tens of similar texts related to ethical principles.
The arguments or details that were given are not convincing, at least
for me. I find that these terms are words of connotation but not denotation,
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as they are not precise terms like, for example, al-bay‘ (the process of
selling), al-nikāh (marriage contract), al-salāh (prayer), or al-siyām
(fasting) are. In other words, the terms [Dr. Bredenoord presented] are
quite expansive. There is no problem with them being this way; what
really matters is how medical doctors and relevant companies will apply
these principles. The insurance and pharmaceutical companies are entities
often forgotten, although they stand at the core of the matter. Sometimes
they are the problem, while other times they end up being the solution if
they behave properly. It would not be fair to push the companies aside and
concentrate singularly on the doctors.
The real issue here is verifying the underlying ground or character of
certain issues (tahqīq al-manāt), meaning ensuring that a certain principle
does in fact match a particular situation in reality. For example, this may
involve the question, “Is this [particular reality] just or unjust?” We have
numerous legal maxims or juristic rules to help us decide. Some examples
are: choosing the lesser of two evils, bringing about good and avoiding
evil, what to do when there is only one resource that everyone is in need
of, and so on. All of this is abundantly specified in Islamic law. Muslim
jurists (fuqahā’) can dissect these terminologies and develop their definitions [to be conveyed to a general audience]. The matter will then be in
the hands of the individual or entity that will actually apply the principles
to reality (muhaqqiq al-manāt). This includes medical doctors as well as
companies. They will be the ones to decide if something is just or unjust.
So what we need at the end of the day is to find those with both technical
expertise in their field and an alert conscience. This could be a religious
conscience, which is the most awake type of conscience, or a civic conscience. What we need is the morally conscious professional to apply
these principles — which do not belong to one civilization but rather are
shared humanitarian principles — to reality.
Mohammed Ghaly
Sheikh Bin Bayyah has stated unambiguously that the principals are universal and belong neither to the East nor the West. Thus, he is in full
agreement with Dr. Beauchamp that, in essence, the principles are universal in nature. The only variance lies in what he called verifying the
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Script of Concluding Discussions: Part Two 395
underlying ground or character of certain issues (tahqīq al-manāt) or
how to apply these principles to real cases. This is where detailing would
be required.
He also stated that in applying the principles to a certain context, we
should be incredibly concerned as to who the person or entity applying the
principle will be. The problem arises if the individual who will apply or
contextualize the principle does not possess praiseworthy morals.
Annelien Bredenoord
I would like to say something about two issues that have been raised. The
first is about context and specification, and the second is about terminology. I would like to start by saying something about terminology because
we entered into a debate about epistemology, particularly with the discussion between Dr. Auda and Sheikh Bin Bayyah, so I would like to ask
their opinion about it. You were saying something to the effect of, in the
West we disagree about definitions and we have deconstructed definitions. However, ultimately, I think we should also discuss here with each
other how we perceive definition. Do you see definition as something
where the truth is somewhere out there and you can have objective meanings of words or definitions of things? Or is it similar to the dominant
view in the West, which is that definition is a social construct and is a part
of the philosophical approach of constructivism in which a definition is
just a social construct, something we get consensus on? Ruth McLean, a
well-known philosopher said that a definition is often more than mirror
terminology. In other words, a definition is not only conceptual but is also
normative. I personally think all definitions are agreements that people
could reach at a certain point of time; they are professionally fixed points
about which we agree, but we also acknowledge that they can be changed
one day. I would be interested to hear Dr. Auda’s perspective on definitions since he initiated the debate about terminology.
The second issue involves specification. Both Dr. Al-Bar and Sheikh
Bin Bayyah stated that in the end we can have universal principles but the
process of specification depends on context in addition to the good morals
of the person responsible for specification. I think we completely agree
that specification itself is something that requires skills and good thoughts.
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There is a method that has been developed for this process called “wide
reflective equilibrium.” The method was developed by the two philosophers, John Rawls and Norman Daniels. They presented what they called
a “thinker.” The thinker is not a one-issue party. So it is not just an insurance company or just a medical doctor. Rather, it is somebody who takes
the position of all relevant stakeholders, so it is comprehensive in nature.
The thinker uses empirical research, considered judgments, principles,
and values and molds them together into a coherent moral position. I do
not think that the aim of principlism is to have one single issue or one
party coming to a very particular point of view. The thinker needs to integrate all relevant stakeholders and all relevant interests. In his book
Justice and Justification, Norman Daniels explained this method. I think
in the end, ethics is all about justification, about whether you can justify
your point of view. If it is merely one position of one single issue, then it
is not justified.
Mohammed Ghaly
I invite comments on this, but I hope everyone takes into consideration
Dr. Al-Bar’s observation in a previous session when he said that if we do
adopt an Islamic system of terminology, we should ensure it is clear and
accessible to non-specialists. At the end, we are addressing physicians, not
specialists in Sharia.
Jasser Auda
I want to clarify the concept of deconstruction (tafkīk) because it has a
large impact on Western thought and, to a certain extent, also on Islamic
thought through the writings of some individuals. As expressed in my
books, I am totally against this concept. I have said that deconstruction
results in historicism, which was called for by Mohammed Arkoun,
Ebrahim Moosa, Hassan Hanafi, and Nasr Abu Zaid. This means deconstructing the authority of the text. In the philosophical sense, this is not
compatible with belief in the sacredness of the words of God and His
direct revelation to His Prophet (PBUH).
The outcome of such an understanding would be the loss of the religion of the Muslim nation (ummah) and the loss of its main source of
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Script of Concluding Discussions: Part Two 397
knowledge and, consequently, its falling into the trap of blind submission
to other nations. At that point, it would not distinguish between what
such nations have of beneficial knowledge (and wisdom is the believer’s
stray camel that he is always searching for (al-ḥikmah dāllat al-mu’min)
on the one hand and what such nations have of exclusively harmful
knowledge on the other hand. The higher objectives of Sharia help protect the Muslim nation from that blind following, by God’s will, because
they assert the concepts of the intellect, justice, education, and freedom
without putting them at odds with the concept of belief. Furthermore,
historicism is not permissible to apply to a text that is revealed by God
Almighty.
Mohammed Ghaly
I invite Sheikh Bin Bayyah to provide his remarks on the following question: If we wanted to define the term justice, or any of the ethical principles, should not the basis or starting point be a text from the Qur’an or the
Prophetic tradition until we arrive at a definition? Or should it be based
on constructivism and social constructs as Dr. Bredenoord mentioned?
Abdullah Bin Bayyah
Firstly, I agree with Dr. Bredenoord that people who have the proper
knowledge and expertise should be the ones to apply these principles to
the specific cases. Secondly, in regards to definitions, I do not think there
is a difference between the West and Islam. A definition is a means of
clarifying something, whether it is an entity, an adjective, or a state of
being. A definition is also a means of illustrating an issue. This can be
done in a number of different ways. For definitions in Sharia, we usually
start with the linguistic definition then move onto the reality of the term
within the context of the Sharia. If it is associated with norms known to
people, then we also mention those. We include three elements: the term’s
linguistic reality, its reality in Sharia, and its customary reality. These
three elements coalesce to form an illustration of the term.
For example, the word ‘adālah literally means balance. It is taken
from the word ‘idl. In the language of the Arabs, ‘idl refers to one of the
saddlebags Arabs would place on either side of a camel, ensuring they
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balanced out. This is where the word justice emanates from. We start from
the linguistic definition of “balance” and then move to the Sharia-based
definition, which is “giving all rightful owners (claimants) their rights.”
We then move to the normative definition or the normative reality of,
“What is a right?” This is answered by Sharia on the one hand and by the
customs and norms of people on the other. Therefore, the understanding
we have is built of different parts: it has to do with the texts, the language,
and the reality. This is how a definition is built in Islam. We have many
resources to refer to about definitions in Arabic, such as The Definitions
of Al-Jurjani (Iṣṭilāhāt al-Jurjānī).
Mohammed Ghaly
I invite comments from our Islamic scholars about the first question we
are addressing related to the four principles, their universality, and their
acceptance or rejection [from an Islamic perspective]. Sheikh Bin Bayyah
said there is no disagreement regarding their universality and that their
application (tanzīl) is where the complications lie. Dr. Bredenoord said
that application or the process of specification does allow room for differences in opinion.
However, Dr. Ramadan has said there is also a problem with universality because these principles are not dry terms but rather are products of
certain philosophical notions and thus we should not be deceived or
deluded by the [apparent] compatibility of the terminology. I think
Dr. Beauchamp also said something similar in our discussions with him.
He said that we do all have to agree on the basis because the issue is
an intellectual one and — as Dr. Al-Bar added — is an issue of human
beings’ natural disposition (fitrah).
Regarding the application of a certain principle, we have questions
like: What is justice? How is justice realized in a certain context and a
certain case? People differ on such questions depending on their religion
and even depending on their disciplines or crafts. An economics specialist
may apply the principle of justice in a way that differs from how a bioethicist would, even if the two were from the same religion, sect, nation, and
society. We agree with the general understandings, but we must know that
these understandings are a product of a certain philosophy, which we may
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agree with in some respects but not in others. If there are any additions or
objections regarding the summary of what we have come to, I invite those
comments now.
Ali Al-Qaradaghi
Firstly, I want to say that the generality of the principles is not problematic
whatsoever, and it is impossible for anyone who adopts a general ethical
rule to escape this generality. Even Sheikh Raissouni chose two general
principles that are more general than the four principles. One is Godconsciousness (taqwá), which applies to one’s soul, to worship, to dealings with others, to everything. The other is mercy, which also applies to
everything and everyone from human beings to animals to other things.
Sheikh Abu Ghuddah also mentioned respecting rules or laws. All of these
things are general. Therefore, if we accept this, then we also are saving
our principles by using the same approach.
Thus, we should not object to the generality of the principles. The
challenge we do have is first with the criteria or standards we use when
interpreting them. The second has to do with the process of application,
which includes the question of who will carry out this process. The application process should be strictly structured. As Dr. Al-Bar mentioned, we
do not want to get confused and lost in discussions that most doctors may
not understand. We should aim for accessibility; the Qur’an did not
address people using complicated philosophical jargon but rather used a
discourse close to their natural disposition (fitrah) so they may understand
it. The third challenge is the ideological background, namely that the four
principles are Western in their character and background.
Mohammed Ghaly
There are four points here. First, there is no disagreement about the generality and universality of the principles. Differences arise in three
aspects. The first aspect is the criteria and standards. Even Dr. Bredenoord
and Dr. Beauchamp acknowledged that the West itself has problems in
this regard. Dr. Beauchamp said previously that there are matters that still
need to be studied.
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The second point of difference is the process of specification or how
we should apply the principles to reality. Sheikh Bin Bayyah mentioned
that this requires someone who is knowledgeable about all the relevant
aspects and gathers them and studies them closely. In principle, we agree
that the person who carries out the specification process should be cognizant and knowledgeable of all the principles so that one principle is not
applied at the expense of others. He should also be well versed in medicine and contemporary medical issues.
The third aspect that Islam and the West differ on is the ideological
background. The four principles are the fruit of a certain ideology, and
similarly the Islamic principles should be born out of the Islamic tradition.
How do we go about doing this? This is the subject of our second main
point. I invite any comments about the first point, about the four principles, before we move on to the second.
Mohammed Ali Al-Bar
Dr. Bredenoord promised some answers to my questions related to autonomy. What do we make of the fact that some governments in the Gulf
require a man and a woman to undergo blood tests for certain common
diseases before they are allowed to get married?
Annelien Bredenoord
The example Dr. Al-Bar gave is a good example of why we need all four
principles and why we cannot just rely on one principle. Autonomy
requires that people can decide for themselves whether or not they are
interested in receiving genetic information. Autonomy also requires what
we call the right not to know genetic information, which is an informed
refusal of information. However, if it was absolute, then patients could
ask for all their DNA and genetic tests without considering the interests
of their relatives or family members, even though information about their
genetic constitution is relevant to what happens with the family members
as well. If a state coerces you to undergo a genetic test before marriage,
I think that would be a violation of autonomy, although the intention may
be one of beneficence. The fact that you at least have to consider the
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Script of Concluding Discussions: Part Two 401
interests of relatives is in my opinion a part of nonmaleficence and of
justice as well. So I think it is a very good example of why we need the
four principles.
Also, it could very well be possible that if I do the process of specification, I would use the same principle and come to a different conclusion
than when you do the specification. This, however, is not a problem
because we accept pluralism at the level of particular moralities. We do
not accept relativism or pluralism on the common morality level, but it is
acceptable if we reach different conclusions. Also, when you were talking
about formulating principles from the Islamic tradition, I think that is not
a problem as long as they are formulated in a way that can be accepted by
all human beings. That is the idea of universality.
Mohammed Ali Al-Bar
My question was only partially answered. The governments in the Gulf
area are imposing a law that anybody who wants to get married must
undergo two or three blood tests in order to avoid the problems that are
increasing in the community due to consanguinity. On the other hand,
there are laws in the West that prevent consanguinity. This is also interference by the law with a person’s autonomy. Governments constantly institute laws that may help the community as a whole but that directly
interfere with [individuals’] autonomy.
I should mention that Islamic scholars have tried to stop the law that
stipulates that two people cannot get married because of the results of
their blood tests. They say that even if both the man and the woman are
carriers of the thalassemia gene or the sickle cell anemia gene, for example, and have a substantial likelihood of bearing children with the disease,
the government should not have the power to prevent their marriage. They
say that the government can give them the knowledge and can provide
them with counseling, but their marriage should not be prevented.
Annelien Bredenoord
This is a public health measure. As is characteristic of public health measures, there is a traditional clash between the principle of autonomy and the
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principle of beneficence or nonmaleficence. All public health measures
like enforced vaccination of children, neonatal screening, and the obligation to wear seat belts in a car are violations of your autonomy. However,
autonomy is not limitless. Our autonomy is violated every day by public
policy and public health measures. I think that is unavoidable. I think
society would be a disaster if we had limitless autonomy. The only question is — and this is the specification process — whether this is a justified
violation of autonomy. I have to think about this more, but I imagine that
you can ask people to undergo tests before they marry. However, you cannot force them to undergo tests and you cannot force them not to marry,
but you can offer them certain options such as prenatal screening.
Abdul Sattar Abu Ghuddah
In the field of positive law, there is a constitution, there are codified laws,
and there are explanatory notes and regulations. The four principles were
presented as if they form a constitution. However, we already have the
higher objectives of Sharia that serve as a more ideal constitution. Accordingly, it appears we can proceed in the following way. We can take the
higher objectives of Sharia as our starting point, and it is not a problem
whatsoever that they can be applied across disciplines because the scholars of the higher objectives of Sharia already intended this. After establishing the higher objectives of Sharia as our ideals or our constitution, we
search for equivalences of the four principles in the Islamic tradition. The
Western scholars or academics have exerted much effort in coming up
with the four principles, so if we find analogues to some of them, we mention these analogues even if we end up using very different terminology.
Next, we move onto the processes of clarifying and detailing or
specification. We describe the limitations of the four principles and add
more principles as needed since four is a small number compared to the
immense field we know biomedical ethics to be. Finally, we link the principles to our Islamic heritage and thus ensure alignment with our religious
tradition.
Sheikh Bin Bayyah mentioned the work of Al-Jurjani as a good
resource for terminology. I would like to mention that we also have
Kashshāf iṣṭilāhāt al-funūn by Al-Tahanawi, Dustūr al-‘ulamā’, and
many others.
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Mohammed Ghaly
We will now move to the second point of our discussions in this seminar
so as to arrive at a number of outcomes. We distributed a document containing all relevant terminology because it appears we are not in full
agreement over common descriptions or definitions. The terms include:
•
•
•
•
•
Fundamental ethics (ummahāt al-akhlāq).
Fundamentals (uṣūl).
Comprehensive rules (qawā‘id kullīyah).
Higher objectives (maqāsid).
Principles (mabādi’).
I ask our religious scholars especially to provide us with their thoughts
so we may define these terms, particularly those mentioned in their
research papers, and try to specify the relationship between all these terms.
Jasser Auda
So that we do not get overwhelmed by a discussion about the differences
between the various terms mentioned, I suggest we focus on answering
the question of what particularly we are looking for in this seminar. As we
decide which term represents what we are looking for, we can arrive at a
definition of that term specifically. Also, we can imagine this term being
included in the title of the book we publish after the seminar.
Ahmed Raissouni
I believe we are going to have a few terms to discuss and choose from:
•
•
•
•
The governing principles (al-mabādi’ al-ḥākimah).
The general fundamentals (al-uṣūl al-‘āmmah).
The comprehensive fundamentals (al-uṣūl al-kullīyah).
The Sharia-based rules (al-qawā‘id al-shar‘īyah).
My own subjective choice would be to use the word rules (qawā‘id):
the Sharia-based rules (al-qawā‘id al-shar‘īyah) or the general rules
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(al-qawā‘id al-‘āmmah). I choose the term rules because it is the most
authentic from the perspective of the Qur’an and its various uses. We are
engaged with rules. However, the rules we have in Islamic law and the
Islamic tradition differ in level; there are rules lower than other rules,
and there are rules higher than others. Thus, we could make it general
rules (al-qawā‘id al-‘āmmah) or comprehensive rules (al-qawā‘id
al-kullīyah).
As I was preparing my chapter, my understanding was that the medical doctor is the main component and thus I focused on ethics and on
God-consciousness and mercy. It has become apparent through our discussions, including those about the four principles, that the matter
extends far beyond the Arabic word akhlāq (ethics) since akhlāq pertain
to the individual’s conduct. Instead, the scope encompasses the society,
government, and policies. The Arabic word akhlāq is not sufficient in this
case, and I do not know whether the English word ethics is sufficiently
inclusive. That is why in my opinion the appropriate term is rules
(qawā‘id), meaning regulations of the society by way of governmental
health policies. We could use either “Sharia-based rules” (al-qawā‘id
al-shar‘īyah) to specify they are based on the Sharia and not something
else or we could use “comprehensive rules” (al-qawā‘id al-kullīyah) to
distinguish them from specific Islamic legal maxims or rules.
Mohammed Ghaly
So we have Sharia-based rules (al-qawā‘id al-shar‘īyah), general rules
(al-qawā‘id al-‘āmmah), or comprehensive rules (al-qawā‘id al-kullīyah).
Abdul Sattar Abu Ghuddah
We have a long history [in the Islamic tradition] with qawā‘id (rules) that
we can refer to, and we can refer to relevant examples and applications
from the past. Furthermore, using this term would demonstrate its rootedness in the Islamic tradition, its long history, and its importance. However,
the word mabādi’ (principles) is somewhat open-ended. Thus, qawā‘id
(rules) is the best option in my view.
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Ali Al-Qaradaghi
Although I have myself used the term maqāsid (higher objectives), I do
not necessarily deem it to be the best choice. It is worth noting that even
if we choose the term qawā‘id (rules), this does not negate the role of the
higher objectives because these rules are nevertheless connected to the
higher objectives.
There may be a juristic (fiqhī) problem with the term qawā‘id: according to the manuals of [juristic] rules, qawā‘id are defined as those which
encompass or necessarily produce religious rulings (ahkām shar‘īyah),
whether prescriptive (taklīfī) or contextual (wad‘ī) in nature. For instance,
“There should be neither harming nor reciprocating harm,” is an example
of what we call a rule.
Ahmed Raissouni
What you stated is the definition of a specifically juristic (fiqhī) rule [not
a rule in general].
Ali Al-Qaradaghi
That is correct. However, I mean that any rule by definition encompasses rulings. A religious rule encompasses religious rulings; a juristic
rule encompasses juristic rulings; and so on. This is why in the title
of my book Mabda’ al-ridā fī al-‘uqūd (The Principle of Consent in
Contracts), I chose the term principle (mabda’) and not rule. Something
like, “There should be neither harming nor reciprocating harm” is a rule,
while something like “consent” or “obligation” is referred to as a principle or theory.
Moreover, the Arabic Language Academy in Cairo has endorsed the
term mabda’, so it is accepted from a linguistic perspective. Basically,
what I want to say is that a rule has to encompass a ruling whereas we are
hoping to develop a theory that includes numerous rules, restrictions, and
limitations. Arising from this it is perhaps best to use the term principles.
However, if we agree that the term qawā‘id (rules) also means mabādi’
(principles), then I would have no objection to its use.
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When it comes to specifying the rules, we should anyhow determine
the source of these rules. What is their background? Their background is
the higher objectives of Sharia, and this demonstrates that we indeed
remain within the same circle of higher objectives.
Mohammed Ghaly
Does using the phrase “comprehensive rules” (qawā‘id kullīyah) absolve
us of the problem with the word qawā‘id (rules)?
Ali Al-Qaradaghi
Using the adjective comprehensive serves to distinguish it from specific
rules, but the comprehensiveness or specificity only refers to their linguistic denotation. As for what the term qawā‘id (rules) means to Islamic legal
theorists, jurists, and religious scholars more generally, qawā‘id always
encompass rulings — whether religious rulings, juristic rulings, rulings of
Islamic legal theory, or grammar rulings. For example, in [Arabic] grammar, every subject of a verb should be in the nominative case. That is an
example of a rule. Nevertheless, if the seminar participants would agree
to use the term rules differently than what all scholars have agreed upon,
I would not object.
Hassan Chamsi-Pasha
In regards to the complete title, I suggest The Comprehensive Rules of
Medical Ethics (Al-qawā‘id al-kullīyah fī al-akhlāqīyāt al-tibbīyah). The
word comprehensive is fitting because once we decide to use the higher
objectives of Sharia, we can say that these comprehensive rules already
imply them.
Mohammed Ghaly
I invite Sheikh Bin Bayyah to offer his thoughts. It seems we are trying to
choose between rules and principles.
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Abdullah Bin Bayyah
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There is a line of Arabic poetry that reads,
Pass from the front of the mountain or the back, for surely
Each side has a path [you can tread securely].
I think both choices [rules and principles] are acceptable. Our early
scholars used the term rule as something that is by definition comprehensive and can be applied to its parts. Therefore, if we choose the
word rule, then the adjective comprehensive would already be included.
That is why I do not see any objection in the last proposal by
Dr. Chamsi-Pasha.
It is worth noting that the French word principaux gets translated as
qawā‘id and mabādi’. However, we usually translate qā‘idah (rule) to
French as la base. For example, we translate al-qā‘idah al-qānūnīyah
(legal rule) as la base juridique. Thus, qā‘idah (rule) and mabda’
(principle) are very similar. In Al-baḥr al-muhīṭ, Al-Zarkashi defined
principles as the boundaries and topics of a discipline that is studied, so
he did define principles in an explicit or particular manner. However,
nowadays we are in the habit of using principles in the sense given by
the popular Western definition, which is completely fine. As Sheikh
Al-Qaradaghi said, as long as the Arabic Language Academy allows the
use of it in that sense, there is no problem. I do not have a decisive opinion on the matter. It would be acceptable to call them general rules
(qawā‘id ‘āmmah) or comprehensive rules (qawā‘id kullīyah) of biomedical ethics. And God knows best.
Abdul Sattar Abu Ghuddah
It is worth noting that a rule unites or links together many different
branches without actually mentioning these branches. In other words, a
rule is a comprehensive and uniting expression — an umbrella — that is
itself derived from many rulings. Note it does not explicitly mention a
ruling but rather is an umbrella for many rulings.
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Hassan Chamsi-Pasha
There is one additional consideration to make about the terms we use.
There is a shift in the West from using the phrase medical ethics to using
the term bioethics. In Arabic, should we add what corresponds to the
prefix bio-?
Mohammed Ghaly
In the West, they have medical ethics, bioethics, and biomedical ethics.
Dr. Beauchamp stated previously that he personally did not prefer the
term bioethics. In addition, medical ethics was an old term; it has been
used in Hippocratic thought. Since the medical field has been through so
much advancement, at one point there was a need for more modern terminology. Thus, both terms were combined to produce biomedical ethics.
Dr. Beauchamp does not seem to object to the use of the term bioethics.
Perhaps Dr. Bredenoord can comment on whether there are any clear-cut
differences between medical ethics, bioethics, and biomedical ethics?
Annelien Bredenoord
Yes, there is a distinction, but this is also a contested distinction. In brief,
one can say that medical ethics is a traditional domain that deals with
ethical issues particula